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416 2"d Street Phone: 209)744-0112 <br /> AM" t <br /> Galt,Ca 95632 Fax: (209}744-0116' <br /> afforda(a�softeom.net Y `` <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements AUG "! 8 <br /> Facility Name: Delta Arco Facility H. <br /> Address: 440 W Charter. Way Stockton,CA <br /> Facility Phone 9:209-465-2487 Z Update of Designated Operator <br /> ❑ New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Natne: ZANE NUYBIO Service Technician <br /> Business Name, AFFORDA TEST ICC#: 5263322-UC <br /> Designated Operator's Phone. 209-744-417.12 Expiration Date: 312/14 <br /> ALTERNATE I <br /> Designated Operator's Name: FELIX RAM) ..TRFZ Serviee'rechnieian <br /> Business Name: AFFORDA TEST ICC#: 52733934-LSC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE 2 <br /> Designated Operator's Name: DAVID WINKLER Service Technician <br /> Bu9iaess Name: AFFORDA.TEST ICC P. 5263373-ITC <br /> Designated Operator's Phone: 209-744-0112 t<,xpiration Date: 3/24.1.4 <br /> ALTERNATE <br /> Designated Operator's Namr. LYLE NTMIVFOService Technician <br /> Rnsincss:riatne: <br /> AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> T certify that,for the facility indicated at the top of this page,the individuals listed above will serve as Designated LIST <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 OWNER(Print): <br /> SIGNATURE OF TANK.OWNER: •' r, - <br /> DATE: 17r OWNERS NE: 2L 412 <br /> NOTE: <br /> 1.) SUBKff THIS COMPt UMD FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: Aww.sr•ater ands�c,�ggy/ust/contacts/coos ax�s.htmL <br /> 2) NOTIFY TILE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATi.ON%T HiN 30 DAYS OF THF <br /> CHANGE. <br /> OFFICE. ( r <br /> County.- ��� Date Faxed: ate Scanned: %' <br />