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416 2""Street . Phone: 209 744-0112 VEC <br /> ffar��.�Te t � � <br /> Galt.Ca 95632 Fax: (209)744-0116 <br /> af[orda(a�softcom.net APR 0 7 014 <br /> Owner Statements of Designated Underground Storage TaIIk Operator <br /> and Understanding of and Compliance with UST ate uirement BEAM <br /> Facility Name: 716 Facility #: Po# DEPARTMEN <br /> Address: &ao cc n t~ r Updated Owners Statement <br /> Facility Pbolle#: +�pc� t�—1 „ 5?0, � ❑Change of Designated Operator <br /> 1 ❑ New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACII,ITI': j <br /> PRIMARY 1 <br /> Designated Operator's Name: ZANE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3/16 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMiIREZ Service Technician <br /> Business Name: AFFORDA"PEST ICC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3/16 <br /> ALTERNATE 2 <br /> Designated Operator's Name: DAVID WINKLER Service'Technician <br /> :Business Name: AFFORDA TEST ICC#: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/10/16 <br /> ALTERNATE 3 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5250492-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date:. 3/3/16 <br /> I certify that,for the facility indicated at the top of this page,the individuals listed above will serve as Designated UST <br /> Operators. The individuals will conduct and document monthly facility inspections and annual facility employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(c)–(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. , ? { <br /> NAME OF TANK OWNER/Operator(Print): T! <br /> SIGNATURE OF TANK.OWNER/Operator! <br /> DATE: OWNERS PHONE: „Zd 91 <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCM,AGENCY(NOT SWR,CB)AFTER SIGNING.TETE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: w}yw_waterhnards.ta.goYLpst/contacts/cupa says html. <br /> 2) NOTI Y THE LOCM,AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 31)DA-'S OF THE <br /> CHANGE. <br /> OFFICE: ,��+` <br /> Cotmty: bs Date Faxed: ,y —7~' Date Scanned: Date E-Mailed _4N. <br />