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4162 eet 209 744-0112 1 1�" <br /> EC <br /> ffC�►rda-Tene Street Phone:_ c <br /> Galt,Ca 95632 Fax:(209)744-0116 <br /> affordaCa-�softeom.net 2014 <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility#: PO# i - HEALTH, <br /> Address: q00 SotA- c-1 Updated Owners Statement <br /> Facility Phone#: ❑ Change of Designated Operator <br /> Q New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <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 Daie: 3/3116 <br /> ALTERNATE I <br /> Designated Operator's Name: FELIX R.A.MIREZ 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 /> ALTERNATE 3 <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: 3/3116 <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 conductand 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 requirements(Statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. / <br /> NAME OF TANK OWNER/Operator(Print): j) ,:5, i2A� 4A� A. <br /> SIGNATURE OF TANK OWNER/Operator: f?I 'i 1��0[�, <br /> DATE: - � � l OWNERS PHONE: .° l <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING,THE LOCAL <br /> AGENCT LIST IS AVAILASL,.F..AT: www.tiv ,&�-bf2grd5.ca.gov/u&t!.r, tac /cu a <br /> 2) AiOTIFY TIRE LOCAL AGENCY OF ANY CHANGES T(1 THIS INFORNIATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> OFFICE. I <br /> (-ounty: Date Faxed: J-7-14~7-14 Date Scanned: nate E-Mailed <br />