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fforda-Te t 4162nd Street Ph ne: (209) 4-011 I2 REC "VED <br /> 1 Galt,Ca 95632 Fa :(209)744-0X16 � <br /> affords softcom.net <br /> Owner Statements of Designated Underground Sto age Tank Operator ,v!4 <br /> 2016 <br /> and Understanding of and Compliance with US Requirements ENV1RONt.,4ENTA i <br /> PERMIT/S HESLTH <br /> Facility Name: My Mini Mart Facility ID# 1094-1 PO# ERVI^ <br /> Updated Owners Statement <br /> Address: 1756 N. Wilson Way Stockton CA Change of Designated Operator <br /> Facility Phone#: 209-941-2264 New Designated Operator <br /> AESIGNATEA UST OPERATOR FOR THIS FACII TY: <br /> PRIMARY Service Technician <br /> Designated Operator's Name: FELIX RA1IIREZ ICC#: 52733934-UC <br /> Business Name: Expiration Date: 2-2648 <br /> TFST <br /> Designated Operator's Phone: 209-744-0112 <br /> ALTERNATE' Service Technician <br /> Designated Operator's Name: DAVID WINKLER ICC ee Technician <br /> Business Name: AFFORDA TEST <br /> Designated Operator's Phone: 209-744-0112 <br /> Expiration Date: 2-26-18 <br /> ALTERNATE 2 Service Technician <br /> Designated Operator's Name: EDWARD STEARNS ICC#: 5250492-UC <br /> Business Name: AFFORDA TEST <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 2-26-18 <br /> 1 certify that,for the facility indicated at the top of this page,the individuals list d above will serve as Designated UST <br /> Operators. The individuals will conduct and document monthly facility inspect ons and annual facility employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(e)—M> <br /> Furthermore,I understand and am in compliance with the requirements(statut s,regulations,and local <br /> ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER/Operator(Print): �O <br /> SIGNATURE OF TANK OWNER/Operator: C <br /> / --7 9 9 7 <br /> DATE! 7/ 6 OWNERS PHONE: y <br /> NOTE: <br /> X) CUSTOMER IS RESPONSIBLE TO UPLOAD THIS FO TO CEItS PER YOUR LOCAL <br /> REGULATIONS.AFFORDA TEST DOES NOT UPLOAD T CERS. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 <br /> DAYS OF THE CHANGE. <br /> OFRCE: pate Scanned: Dare E-Mailed <br /> County:San Joaquin Dete Fazed: <br />