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RRCCTVED 9312112014 16:09 <br /> MAR-21-2014 15:54 FROM:H TO: '7440116 P.1/1 <br /> �Z I M E® <br /> 4141 too , 2 Fatc:c ) R 0 7 2014 <br /> ffor"'a-le rllp,CA <br /> stfords ttcom. <br /> e741"topertOENVIRONMENTAL HEALTH <br /> �Jpder�'onpd�tora� DEPARTMENT <br /> owner Stateaaents of tWipaced of and Compliance witb UST RegUit991e0 <br /> And Underatandin>: <br /> Facility#: 1275-1 PrSa <br /> (Spdattsd Owna'e Stmteoeltt <br /> Facility N*Ve.Unitcd 95205 Q cw=If 1 �d""or <br /> Addrese: 3440 l;Maw 9e Stockton CAte�I dp�atar J <br /> FAcllity pilope#:205-b62.OZ94 U <br /> N It FOR T <br /> DFS om' <br /> PRIMARY &rvlct Ttc2+ald.e <br /> p�ygastad Cl{wtet.,'s Namct ZANE NT"O iCC ll, 5263JU-IX <br /> lsusineae Hwsc: p,FRORUA TEST c:ptrattoa Daw. 34116 <br /> U,apstcd 00—tof's rAotus ga41 ott2 <br /> ALTERNATE i $ervipo'PceYniefaa <br /> pestanated(AwmWil Nam; nLlX RA 9=Z ICC ti:3"3"'UC <br /> 90jam name: Aff OADA TEST Ewpimtioa Date: 313/!6 <br /> Jatromttd(*rotor'-}hoes 29VA"112 <br /> ALTLRN ATE 25efvkc Trr <br /> nleebaide.laustcrs <br /> ied Ootsr`a N.MV DA") TE5) f R ICC a:SU3313-UC <br /> �Ypi <br /> Dnsin,xr Nara: ntina Dam 3/10!16 <br /> De,jXnatedoper.tor%Phanc, 7.09-74"112 <br /> AI,TMNATE 3 SgyietTechnklan <br /> Dcskamted OUtr.tor's Name, EDWARD SIMARNS JCC b 67.10992-UC <br /> Bdlli a Name,. AFFORDA TEST Eipirstlnn Datt: UItti <br /> DLflst W"Open WIS I'o t: Z04.74"1.12 <br /> I eertW that,for the facility led icatvd at the MP of this Pana the individrlmls listed mbove will terve Aa!]ot"ted US',r <br /> opefyttors. The lndlvldumis will condad and ltocurnant monthty ACURY IngP.ctions and entluai fmc3[lty employer <br /> tnitlirag,is <br /> Amordence with Call(brnisl Code of RegUbMa+m,title 23,section x715(c)– <br /> Forthcrmore,I wade r'itnnd mind am in eamplimpco with the requirements(atwt*tw,tegulattons,and local <br /> Ordinmoem) applteablo to u►hdergroU06 storage tante, <br /> NAM S OF TANK OWNCR.(print): H�K <br /> SIGNATURE OF TANK OWINEW <br /> DATE: r OWNER PHONE: Z <br /> NOW; HN(Y(NOT 3WAf$J AFTER SICNTNG.THE LOCAL <br /> 1) t1t1pKff THIS COMPLETIEO FOitM'rO'If1E LOCA t.AG ntar <br /> AGENCY LIST fS AVAlt�11�Al' r+ <br /> 2)NtXI II?Y THE LOCAL AGENGX QF AIVV C NGU;TO-11315 I1NrL'K—'i7ON Wl l tIIN 3o RAYB OF THE <br /> CHANGE. <br /> OFFICE.,Couy. t�f Scannas: <br /> 4+ Date 19-MaNO <br />