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Tp _ <br /> AVE® <br /> fforda-Te 416 2^"Street Phone: (209)744-0112 <br /> Galt,Ca 95632 Fax: (209)744-0116 APR 0 2014 <br /> affords softcommet <br /> Owner Statements of Designated Underground Storage Tank OperaffiWIRON MENTAL HEALTH <br /> and Understanding of and Com Bance with UST Requirements nFPAPTM NIT <br /> Facility Name: g�,jA UWe6VxFacitity4: PO# <br /> Address: Z�' n S 1 -4%u i l�ujck Z Updated Owners Statement <br /> Facility Phone#: ---1Ck1-W CA q S-a-3l� ❑Change of Designated Operator <br /> Ol co!�a G 9 L.2-?— ❑ New Desigoated Opt—tar <br /> DESIGNATED UST OPERATOR FOR THIS FACMITY: <br /> PRIMARY <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 /> ALTERNATE ] <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: 3/3/16 <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 /> ALTFRNATE3 <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 010ployee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(e)-(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/Operator(Print): -��s , IA-C IA <br /> SIGNATURE OF TANK OWNER/Operator <br /> DATE: 3 I L 1 �?.O I yt OWNERS PHONE: �q is a S o O(O <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: www to boards ca eqv/ust/confaNslcuoa aays.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> OFFICYi: tl�"1') <br /> Coaaty:5� Date Faxed: Date Scanned: Date E✓Mafled <br />