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2014-03-11 12:53 TRACY "UCK STOP 12098322312 > 2094683433 P 111 <br /> fforda-Tet <br /> ED <br /> TaifordaQsoftcom.aet <br /> 2n°Street Phone:(209)714.0112 <br /> t,Ca 95632 Fax:(209)744 0116 <br /> M^.-t 1 2014 <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements ENVIRONMENTAL <br /> Facility Name: Facility#: POq <br /> Address: 711 —a-C-+.1 �j LV Upd ted Owners Statement <br /> FacilityPhone#: ElChan:c of Designated Operator <br /> PZC( gG <br /> a (W -1 L} ❑ New I Itsignated Operator <br /> DESIGNATED Uff OPERATOR FOR THIS FACILI <br /> PRIMARY <br /> Desizasted Operntor's Name: ZANE NIMMO Seryi a Technician <br /> Business Name: AFFORDA TEST ICCIA: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expij ation Date: 3/3116 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Sera,ce Technician <br /> Business Name: AFFORDA TEST ICC . 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiation Date: 313/16 <br /> ALTERNATE2 <br /> Designated Operator's Name: DAVID WINKLER Scrvi c Technician <br /> Business Name: AFFORDA TEST JCC : 5263373-UC <br /> Designated Operator's Phone: 209-7440112 Expir tion Date: 3/10/16 <br /> ALTERNATE3 <br /> Designated Operator's Name: EDWARD STEARNS Servi c Technician <br /> Business Name: AFFORDA TEST ICC : 5250492-UC <br /> Designated Operator's Phone: 209-7440112 Expij ation Date: 3/3116 <br /> 1 certify that,for the facility indicated at the top of this page,the individuals listed above will ser ve 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,tine 23,section 2715(c)-(f). <br /> Furthermore,i understand and am in Compliance with the requirements(statutes,regulations,sad local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER/Operator(Print)�JCw LA 4'R <br /> SIGNATUREI OF TANK OWNER/Operator <br /> DATE: 3 1 t 1 `7.0 I t �' OWNERS PHONE: 5 0 0(0 <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(.NOT SWRCB)AFTER IGNLNG.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: r v/ s <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 10 DAYS OF THE <br /> CHANGE. <br /> OFFICE: <br /> County: Date Fazed: Date Scanned: Date E-Mlied <br />