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08/0312012 16:14 FAX 2097440116 IQ]0001/0001 <br /> iorda-Tie t 4162nd Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax. (209)744.0*16 <br /> fforda@§oftcom.net I AU; 0F <br /> Owner Statements of Designated Underground Storage Tank Operatolr <br /> and Understanding of and Compliance with UST Requirements �v <br /> Facility Name: Rai- r {`p n FaeliIity#: <br /> Address: ,+E.. w '-tYit -br.it-c� S'ruc3— y-x GP, <br /> Facility Phone#: ,Ok Li L�–Sol Jj fli]Ci�g of fesi.,ated opmti0r <br /> DESIGNATED UST OPERATOR FOR TTIIS FACILITY: 11 <br /> i <br /> PRIMARY <br /> Dcaignated Oprrat»r's Nxme: ZANE NIMMO Service Technician I <br /> Business Name: AFFORDA TEST TCC is 526332.2-UC <br /> Designated Operator's Phone: 209-744-.()112 Expiration Dati. 312/12 <br /> ALTERNATEI <br /> Designated Operator's Namur FELIX RAMIRicZ Service Technician i <br /> Bvsinw Name: AFFORDA TEST iCC*: 52733934-UC <br /> Designated Operator's Phone: 209-744-D 112 Expiration Lata; 47/12 <br /> ALTERNATE2 <br /> Designated Operator's Name: DAVIT)WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC 4; 5263373-UC <br /> Designated Operator's Phone: 209-7440112 Expiration Hate: 3124/12 <br /> ALTERNATE 3 <br /> Designated Operator's Name; LYLE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Photic: 209-744-0112 Expiration Date: 24112 <br /> 1 certify that,for the facility indicated at the top of this page,the individuals fisted above will serve as Dcsignated UST <br /> Operators, The individuals will conduct and document monthly facility inspections and annual facility employee training,in <br /> Accordance with California Code of Regulations,title 23.section 2715(C)—(f). <br /> Furthermore,I understand and am in compliance with tate requirements(.statutes,regulations,and 1061 <br /> Ordinances) applicable to underground stornge tanks. <br /> NAME OF TANK OWNER(Print): y'i J A- <br /> STGNATURE OF TANK OWNER: <br /> e <br /> DATE= <;63v2 OWNERS PRONE: 1,0 <br /> NOTF. <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT S WRCB)A1%TFR SIGNING.TIE LOCAL AGENCY <br /> LIST IS AVAILABLE AT; wt%w,wAf��pards.ett acrvltr�Vm /surf tr11 i- <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANCES TO THIS INFORMATION WMflN 30 DAYS t7F,ri4E CF1ANoE. <br /> OFFICE: <br /> Colinty: ,�^ c�l✓L Date Faxed: g�3 l2 Date Scanned: 1! S 3 2 <br /> i <br />