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Pop22 l0 <br /> ffo rd a_Te t 416 2aa Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax: (209)744-0116 <br /> affords softcom.net <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: '-"rte V Veit Facility#: PON <br /> Address: ,3-r-)S 'T"" 9-4'\j A E Updated Owners Statement <br /> Facility Phone#: 1 0-4e)," CAts' X1513-1(0 ❑Change or Designated Operator - <br /> �_.C.1 New Designated Operator . <br /> PRIMARY DESIGNATED <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: RECEIVED <br /> Designated Operator's Name: LANENIMMO Service Technician - <br /> Business Name: AFFORDA TEST ICC#: 5263322-UC <br /> 7. <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 32/14 FEB 18. 814, <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service Techntan ENVIRONMENTAL HEALTH <br /> Business Name: AFFORDA TEST - ICC#: 52733934-Ue - DEPARTMENT <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3JV14 <br /> ALTERNATE 2 <br /> Designated Operator's Name; DAVID WRIKI.ER Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/V14 <br /> ALTERNATE3 <br /> Designated Operator's Name: LYLE NIMMO Service Technician <br /> Business Name: AFFORDA TEST - ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 312!14 <br /> ALTERNATE <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC# 5250492UC <br /> Designated Operator's Phone: 209.744-0112 Expiration Date: 12/29/14 <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 facilhy,employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(c)—(1). <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): <br /> SIGNATURE OF TANK OWNER/Operator: <br /> nrLS <br /> DATE: 1 - a - 1? OWNERS PHONE: $..09 <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.mterboards.ca.aov/usVcontactalmoa sevs html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> OFFICE: <br /> County: (\/Date Faded: Date Scanned: <br /> DateF Maikd <br />