Laserfiche WebLink
fforda-Tet 416 2"" Street Phone: (209)744-1)112 <br /> Calt,Ca 95632 Fax: (209)744-0116 <br /> afforda@,softcoin.net . 2013 2�L <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Comeliance with UST Requiremefits <br /> Facility Name:W V��-JrCp Facility #: PO# <br /> Address: LA44 W -(ktaAr CA Z Updated Owners Statement <br /> Facility Phone 4: -148)7 IlChange of Designated Operator <br /> New Designated Operator <br /> _DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: LANE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC N. 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date. 3n/14 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service"technician <br /> Business Name: AFFORDA TEST ICC#: 52733934-tJC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE2 <br /> Designated Operator's Nome: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC N: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date; 3/2/14 <br /> ALTERNATE3 <br /> Designated Operator's Name: LYLENIMMO Service Technician <br /> Business Name-. AFFORDA TEST ICC#: 5249115-LIC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2t14 <br /> ALTERNATE 4 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC N 52$049241C <br /> Designated Operator's Phone. 209-744-0112 Expiration Date: 12/29/14 <br /> 1 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 requirements(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNERJOperator(Print): #A A1- -rr jok) <br /> SIGNATURE OF TANK OWNER/Operator : <br /> DATE: OWNERS PHONE: <br /> NOTE: D1 L4 1 lot <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: <br /> CHANGE.2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TUfifliS INFORMATION WITHIN 30 DAYS OF THE <br /> OFFICE. <br /> County: (y, Date Faxed: Date Scanned: 3-1t, <br /> O)t Date E-Mailed2- <br /> 2ya _ <br />