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'27/2011 18:08 FAX Q0001/0001 <br /> 2/22!2011 01:54 209465; J AEC FOOD MART PAGE 01/02 <br /> vec cc i ucu i p HrrVt<uH t t:- 20.9-74401'18 <br /> P,2 <br /> E:N <br /> Lforda Te 416 Zrd street Whose:(209)744-0112 <br /> colt,ca 95632 JF;Qx:(2M 744-011-6 <br /> affords oitcamntt <br /> Owner Stfe>ments of Design ted Uade pttud Storage Wank operator <br /> clad Uadelrstandimg of and C lv�gIiance " h UST Recesiremeats <br /> 'aGilif3? arae: Facility#: <br /> Address: Zt=NtAUST <br /> FacWtyPhone#: — ��� �ChaugeofDe�uatedaperator <br /> NewDesignated Opaatar Q E-RAT R FOR THIS IPAL= <br /> PRIMARY <br /> Dens rsted Operator's Name: ZANE Nmo Savia TecbMeim <br /> BuzinexsiYamm AFFORD, TEST ICCtY: 5263322-Uc <br /> Designated ppetatof's PbonG 209-744-0114 A •' Fxpirarionp�r" 312112 <br /> ALTERNATE 1 a i <br /> D-j,Msted QpCratae's Name: FELIX RAImz 'LOAN service Teeflnie``ssa <br /> su5in=Namc: AIR70RDA TEST O�C <br /> y y TCC#: 52733934-UC <br /> Designated Operator's Phone: 209-744.0;11 " , <br /> 1+xpiraIIan Dates 417112 <br /> ALTERNATE 2 11ZKp <br /> D�-;T=d OpemmesName: DAVTn X?LNKLER c <br /> :nuke Teckvcian <br /> E3usir%=N=m AFFORD*TEST- TCC-#. 5263373-UC <br /> DmignalcdOmmor'sPlo=; 2o4-744•ol1� ExpiradcuDatc: 3iWI2 <br /> ALTERNATE 3 <br /> Dmicoated Operator's Marne: LYLE N1ftK0 Scrvicc Techniciao <br /> Business Nacre: AFFORDS TEST ICC k: 51491 IS-TJiC <br /> Des'mamed Operator's ebone: 209-744.0112. Exoraaion Date: 2/W12 <br /> 1 certify that,for the facility indicated at the top of this p e,the individuals listed above will serve as Dcsignstcd UST <br /> Operators. The ixtdlvlduals wil I conduct and document m atb'ty facility Inspections and amt iat faoitity employee training in <br /> Accordance with Calci mia Code of Regulations,title 23. cction 2715{e)—(f), <br /> Fu"bcrmore,I understand and:Lyn iu cornplisaca with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to undergrouuO d storage tan <br /> .NAME OF TANK OWNER(Print): <br /> SICYNATURE OF TANK OtVP1T;R: <br /> rS PHONE: <br /> E) SUBMrr nils CDMPLE'1'1JJ3 FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGN-TING.THE LOCAL_AGENCY <br /> LIST IS A'VAB.ABLE AT: ttWconmcWcn"anvshhnt. <br /> T,1 1 Cr=THE LOCAL AGPe,N OF ANY CH ES TO THIS WFOPMATION WUH N 30 DAYS OF THE CjfANGE. <br /> OF,FLCE <br /> Coattty: : ate Fazed: .2 1 Date Scanned- 2 l f <br /> I <br />