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f f o rid a 1 A t 416 2nd 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: J&L Market Facility ID# 1576-1 PO# <br /> Address: 8115 S El Dorado St French Camp 95231 ❑ Updated Owners Statement <br /> ❑ Change of Designated Operator <br /> Facility Phone#: 209-982-0897 ® New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <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: 2-26-18 <br /> ALTERNATEI <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: 2-26-18 <br /> ALTERNATE 2 <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: 2-26-18 <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 employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(c)—(f). <br /> Furthermore,I understand and am in compliance with the re . ments(statutes,regulations,and local <br /> ordinances)applicable to underground storage tanks. n /� <br /> NAME OF TANK OWNER/Operator(Print): \\vJ� <br /> SIGNATURE OF TANK OWNER/Operator: <br /> DATE: OWNERS PHONE: �� ) �V 0 C <br /> NOTE: <br /> 1) CUSTOMER IS RESPONSIBLE TO UPLOAD THIS FORM TO CERS PER YOUR LOCAL <br /> REGULATIONS. AFFORDA TEST DOES NOT UPLOAD TO CERS. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 <br /> DAYS OF THE CHANGE. L <br /> OFFICE.- <br /> County: <br /> FFICE.County: Date Faxed: Date Scanned: Date E-Mailed JUN 2 4 2016 <br /> + <br />