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12/10/2010 16:36 FAX 100001/0004r,����� <br /> 2 017- <br /> Cufox�da'�'Te 416 2"d Street Prone:(209)744.0112 <br /> Galt,Ca 95632 Fax: (209)744.0116 DEC 10 2000 <br /> affarda oftcom.net <br /> Owner Statements of Designated Underground Storage Tank Operator SAN COUNPI <br /> and Understanding of and Compliance with UST Requirements �Fdvi�'r :� ,:'=i•rT,dL <br /> HEALTH D1-7�,a FITMENT <br /> Facility Name: Rai- (3L;,Lc b Facility#: l 02 0- <br /> Address: q 11 C \,— 3\vn m -� `iS33b <br /> Facility Phone#: �Z3L_ -j 1 S- ❑Change of Designated Operator <br /> (---XXDX <br /> New Desif!natcd Operator <br /> DESIGNATED UST OPERATOR FOR THIS F.A,CILUX: <br /> PRIMARY <br /> Dcsignatcd Operator's Name: ZANE NIMMO Service Technician <br /> Business Name: AFE'ORDA TEST ICC 4: 5263322-UC <br /> Designated Opera.`or's Phone: 209-744-0112 Expiration Datc: 3/2/12 <br /> ALTERNATEI <br /> Drzignatcd Operator's Nat= FELIX RAMIREZ Service Tcchnician <br /> Businms Name: AFFORDA TEST ICC#: 52733934-LIC <br /> Designated Operator's Phone: 209-74401 I2 Expiration Date_ 4/7/12 <br /> ALTERNATE 2 <br /> Designated operator'sNarne: DAVIDWiNKLER ServiccTechnicinn <br /> Business Names AFFORDA TEST ICC#: 52633'73-UC <br /> Designated Operator's Phonc: 209-744.0112 Expiration pate: 3/24/12 <br /> ALTERNATE 3 <br /> Designated Operator's Narne: LYLE N1MMO Service Technician <br /> Busincm Namc: AFFORDA TEST ICC#: 5249115-LSC <br /> Desigmted Operttor's phone. 209.744-0112 Expiration Date: =4/12 <br /> 1 ccrdfy that,for the facility indicated at the top ofthis page,the individuals listed above will stave as Dcsigrated UST <br /> Operators. The individuals will conduct and document monthly facility in-cpoctions and annual facility employee 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(.vtatutc%regulations.and local <br /> Ordinances) applicable to underground storage ta <br /> n <br /> jjks. <br /> NAME OF TANK OWNER(Print): /'rr�ln OLr;�,l J� t <br /> SIGNATURE OF TANK OWNER: <br /> DATE:11/1/10 OWNERS PHONE: NVQ r 5 S3 3L `�o <br /> NOTF: <br /> 1) SUBW7 THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THF LOCAL AGENCY <br /> LIST IS AVAILABLE AT: wr«v,w9(�rbt�ards,t/e.aov/ir�t/c�nts/con Lt�gys.htm�. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE: c ' <br /> Cotrnty:�, lye ll :_-,i.V,-N. Date Faxed: Date Scanned: <br />