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S L.c. 1 : b E-;-- <br /> Afforda-TeSt 416 2nd Street Gait,Ca. 95632 209-i=-AA113 209 744-0116 FAX <br /> f1wne:r Smrem-nt-s Fsf De-sigrated Uiidergratzad Starag <br /> e Tank r <br /> and Understanding of and Compliance with UST Requirements <br /> 6 <br /> Address: A,_l C> LkA C <br /> Reason forth is <br /> t <br /> Ct <br /> OCT 132009 <br /> PRIMA-RY SANP , <br /> ENVJRn,:-"1JNTy <br /> HEALTH <br /> ausiness Name: <br /> Desienated Onerwor's Phone 9-. 24)9 744-( 112, Fvniratinn Date 711/)009 <br /> R ATE I <br /> Desienated Operator's Name- DAVID A.WUNICLER Service Technician <br /> ' 26.�J0 Jr..) <br /> Designated Operator's Phone 4: 209 744-0 1 12 F-Pirstion Date,. 3J27/2Q1.0 <br /> ALTERNATE 2 <br /> FDesignated Operator's Name: ZANE A. NIMMO Service Technician <br /> Designated AF FORDA-Tr E S T 5--1613 3 2 2- <br /> Designated Operator's Phone 9: 209 744-0112 Expiration Dale: 3/14/2010 <br /> Put ILN A f E 3. <br /> Designated Operator%NRIE <br /> ame: FELIX G ANURZ Service Technician <br /> D--e <br /> BusinAfss NarnckFTFORTJ-A--o-L C C 5"17 jY4 <br /> Designaled Operator's Phone 9-. 20 744-0112 Expiration Date. 6P-112010 <br /> T cer.ify that. for the facil oy indicatcd at the top of this pa the individuals listed above will serve as Desig7lated UST <br /> Operators. The individuals will conduct and document monthly facility inspections and annual facility employee training.i <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br /> ordinances) appLicable to underground storage tanji-s. <br /> NAME OF TANK OWNER (Print):_ <br /> FL <br /> SIGNATURE OF TANK OWNER: <br /> C11 0 a VIC PHONE: <br /> DATE: �7- <br /> 1)SUBMTTHISCOMPLETED FORM TOTHE LOCALAGENCY(NOT STATE WATER RESOURCES CONTROL BOARD)AFIMrE ,"; <br /> 2)NO-nFY THE LOCALAGENCY OF ANY CHANGES TOTUIS IN FORMATION WITHIN 30 DAYS OF THE CHANGE. <br />