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lI J RECEIVED 10/16/2015 09:07 <br /> 10/15/2015 14:24 2093697813 WINE COONTRV STATION PAGE 01 <br /> - ffOC(I$-Tet 416 Ye Street Phase:(289)7440112 — <br /> Cuit.Ca 9W2 Fat:(209)744-0116 <br /> _y afford �.wDrnm.Ml __ _ <br /> Q< Owner Statements of Designated Underground Storage Tank Operator <br /> and Understandingof and Com liance with UST Requiremenis <br /> Facility Name: 'ARC. RSM Q it\ Facility N: PDR <br /> Address: 1,A g.s s S• tit CA4NW Ay 99 ST.IK'CAN upda(ed Owner statement <br /> FacilityPhone M: Za1_1Lt8- Z4 S$ ❑(untturiwomsew(Iprmw <br /> p Nr Ilalaaova O,wrsw <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY' <br /> PRIMARY <br /> nrdpalyd Operator',Nur: ZANE NIMMO Semi"Technician <br /> Baine s Name: AFFORDA TEST ICC R: 5263322-UC <br /> Designated Operator's Phone: 209.744.0112 Expiration Date: 3IN16 <br /> ALTERNATE <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICC R: $2733934UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3IN16 <br /> ALTERNATE 2 <br /> Designated Operator's Name: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICCN: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: N10116 <br /> ALTERNATE3 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC R: 5250492-UC <br /> Designated Operator's Phone: 209-7440112 Expiration Date; NN16 <br /> 1 certify that.Inc the facility Indicated at the top of thle page,the Indlvidsals listed above will sena an Designated LIST <br /> Opereenre. The ladividnals will eooducl and donmal monthly fa611ty Iarpeetior*ad auaal facility employee <br /> training.to <br /> Accordance with California Code of Reg latioa,title 23,section 2715(c)-(D. <br /> Furthermore,I nMaralsod and am In compliance with the requirements(statutes, rad local <br /> Ordtaaesl applicable to underground storage ranks. <br /> t <br /> NAME OF TANK OWNER/Operator(Print): <br /> SIGNATURE OF TANK OWNER/Operstor: <br /> DATE: /U I _ OWNERS PHONE: J0 I - -19 1- 74-xe�J <br /> NOTE: <br /> D S(aMR'THIS CTIMPLFMD FORM TO T'HE I.O(:AI.A(:KNC'V(NOT SW R(7)AFFER SIGNING.THE LOCAL <br /> AGE(I LM WAVAIIAaIa:AT: <br /> 2)NOTIFY THE LOCAL AGF.W'Y OF ANY('III TO THIS INFORMATION WITHIN 38 DAYS OF THE <br /> (HANGF- <br /> O"Irc- <br /> (wary: Dale Fasd: _—. _.._. qw Saerd: Dote 4htaard <br /> Scanned by CamScanner <br />