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1/ C <br /> fforda-Te t 416 Galt,Ca 956 Fax;( (209)744-011 <br /> Gait, a 95632 Fax:(209)744-0116 <br /> affords nnnnaaaa qnflentri.ir 014 <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Re uiremen EALTH <br /> Facility Name: Short Stop Facility#: 1101-1 PO# 171=0A RT-MENt <br /> Address: 20 A Turner Road Lodi CA 95240 ® Updated Owners statement <br /> Facility Phone#:209-369-3697 ❑Change of Designated Operator <br /> ❑ New DcsigMW Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACI LIW: <br /> PRIMARY <br /> Designated"rotor'sName: ZANENIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263321-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3116 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3116 <br /> ALTERNATE2 <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 <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 /> 1 eertil'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)—(t). <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(Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE; OWNERS PRONE:916-955-5661 <br /> NOTE: <br /> 1) $VaMTi THIS COMPLETED FOAM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.TFiE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: www'waterhaards.ce eo /u t/eoataetshuaa aovs.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 3o DAYS OF THE <br /> CHANGE, <br /> OFFICE. Date Footed: �'1'1�. Date Scanned: <br /> Data F—Malted <br />