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0 1e r <br /> � '-d <br /> T <br /> ffo rd a 1 416 2"4 Street Phone: (209)744-0112 <br /> N Galt,Ca 95632 Fax:(209)74"116 '3 0 5 2014 <br /> afforda@softcom.net <br /> Owner Statements of Designated Underground Storage Tank CtPNMONMENTAL <br /> and nderstanding of and Compliance with UST Re uiremetWALTH DEPAFJTMENT <br /> Facility Name: or+ —9)2iV Facility #: PO# <br /> Address: aC)A W - -"tt/!^{f" fZ L�QrAb (A Updated Owners Statement <br /> Facility Phone#cz-0 q)` X j C El Change of 1)"iEnated Operator <br /> l D T ❑ New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: ZANENIMMO Service I irhnician <br /> Husinesa Name: AFFORDA TEST R14: 52633224JC <br /> Designated Operator's Phone: 219-744.11112 Expiration Date: 3/L14 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service"technician <br /> Haainess Name: AFFORDA TEST ICC a: 52733934-11: <br /> Designated Operator's Phone: 219.74441112 Expiration Date: 312!14 <br /> ALTERNATE <br /> Designated Operator's Name. DAVID WINKLER service Technician <br /> Business%AMC: AFFORDA TEST ICC#: 526337341C <br /> Designated Operator's Phone: 209444.0112 Expiration Date: 372114 <br /> ALTERNATE3 <br /> Dnlgnalyd OlieralorNName: LYLENIMMO semi"Technician <br /> Business Name: AFFORDA TEST ICON; 5249115-LIC <br /> 1)"ignmed Operator's rimae; 209-744-0112 Expiration Date: 3WI4 <br /> ALTERNATE4 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST I4CC#52%492.11C <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 12/29/14 <br /> 1 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, 1 understand and am in compliance with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNERIOperator(Print): <br /> SIGNATURE OF TANK OWNER/Operator: <br /> DATE: /-00 Z()1 LfOWNERS PHONE: 'T16 " y'17'''..S I <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCa)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: www.waterhauda.ca.elerlusttcuntactstsuoa agvs.himl. <br /> 2) NO'17FV THE LOCAL AGENCY OF ANY CHANGES-1.0 THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE <br /> OFF/CE: <br /> County: Date Faxed: Date Scanned: <br /> Date E-Mailed �2 ' <br />