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At _----------, 416 2nd Street Phone: (209)744-0112 0"J 0 .2 71113 Galt,Ca 95632 Fax: (209)744-0116 i afforda(q-),softcom.net 7 s1,� Owner Statements of Designated Underground Storage Tank Operator and Understanding of and Compliance with UST Requirements Facility Name:Ui, Il<A Facility #: PO# Address: 1440 W Charter Wav Stockton CA Z Updated Owners Statement Facility Phone 9: ❑Change of Designated Operator ❑ New Designated Operator DESIGNATED UST OPERATOR FOR THIS FACILITY: PRIMARY Designated Operator's Name: ZANE NIMMO Service'rechnician Business Name: AFFORDA TEST ICC M. 5263322-UC Designated Operator's Phone: 209.744-0112 Expiration Date: 31V14 ALTERNATE l Designated Operator's Name: FELIX RAMIREZ Service"technician Business Name: AFFORDA TEST ICC#: 52733934-UC Designated Operator's Phone: 249-744-0111 Expiration Date: 3/2/14 ALTERNATE 2 Designated Operator's Name: DAVID WINKLER ServieeTechnician Business Name: AFFORDA TEST ICC#: n6337341C Designated Operator's Phone: 209-744-0112 Expiration Date; 3/2/14 ALTERNATE 3 Designated Operator's Name: LYLE NIMMO Service Technician Business Name: AFFORDA TEST ICC#: 5249115-CIC Designated Operator's Phone: 209.744-0112 Expiration Date: 3/2!14 ALTERNATE 4 Designated Operator's Name: EDWARD STEARNS .nervier Technician Business Name: AFFORDA'PEST ICC N 5250492-11C Designated Operator's Phone: 209-744-0112 Expiration Date: 12/29/14 1 certify that,for the facility indicated at the top of this page,the individuals listed above will serve as Designated UST Operators. The individuals will conduct and document monthly facility inspections and annual facility employee training,in Accordance with California Code of Regulations,title 23,section 2715(c)—(f). Furthermore,t understand and am in compliance with the requirements(statutes,regulations,and local Ordinances) applicable to underground storage tanks. NAME OF TANK OWNERIOperator(Print): PA Adir 's ,/h) SIGNATURE OF TANK OWNER/Operstor : DATE: NOTE: OWNERS PHONE: ( ` `lot 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL.A(;1.\('N'(NOT SWRCIi)AFTER SIGNING.THE LOCAL AGENCY LISTIS AVAILABLE AT: N,t.0 atcrb: rd+.ca.�, CHANCE.2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES To I I I 11N1NFORMATI6N'WrrHtN 3o DAYS OF THE OFFICE; County: (1, Date Faxed: Date Scanned: 1�--/:p —bt Date E-Mailed q,2{z ..