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..,Dec 22 11 02:01 p AFFORDA TEST 209-744-0116 p.2 <br /> fforda Te t 416 2nd Street Phone:(209)?44-0112 <br /> Galt,Ca 95632 Fax:(209)744-0116 <br /> affords oftcom.net <br /> Owner Statements of Designted Underground Storage Tank Operator <br /> and Understanding of and C mpliance with UST Requirements <br /> Facility Name: 'C <br /> FnrjA Facility#: <br /> Address: .71-6 IFL o v` V <br /> Facility Phone ik Z09 9 ® Change of Designated Operator <br /> ❑ New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: ZANE i\1 MO Service Technician <br /> Business Name: AFFORD TEST ICC#: 5263322-7LIC <br /> Designated Operator's Phone: 209-744-011 Expiration Date: 3/V12 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX 11.4MIREZ Service Technician <br /> BusinessNamc: AFFORDA TEST ]CC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 4/7112 <br /> ALTERNATE 2 <br /> Designated Operator's Naine: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA,TEST ]CC#: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/24/12 <br /> ALTERNATE 3 <br /> Designated Operator's Name: LYLE NIMMO Servicc Technician <br /> Business Name: AFFORDA TEST [CC#: 5249115-UC <br /> Designated Operator's Phone: 209-7440112 Expiration Date: 2J24(12 <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 training,in <br /> .Accordance with Califomia Code of Regulations,title 23,�ection 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 /> N /�AME OF TANK OWNER(Print): `mg RL—C� (/y(J7 A/ <br /> SIGNATURE OF TANK OWNER: <br /> DATE: / � ll I OWNERS PHONE: �! Co'j <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL AGENCY <br /> LIST IS AVAILABLE AT. ",,.v.Waterboards_ca.eov�ust/contecct/cuoa az s.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHA E5 TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE: <br /> County: ate Faxed: Date Scanned: <br /> � n <br /> r <br /> Vr <br />