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04/27/2012 10:13 FAX <br />[in 0001/0001 <br />orf� Te 416 2'd Street Phone: (209) 744#112 " <br />Galt, Ca 95632 Fax: (209) 744-0116 <br />affords oftcom.net <br />Owner Statements of Designated Underground Storage Tank Operator 2 775T, <br />and, Understanding of and Compliance with UST Requirements <br />Facili Name: -� <br />Address: ��35j �' l7�c�i�l•rr!,� �1e �..pia�1a� t1P�f�TE Z7 <br />Facility Phone #: Ghmi, of Designated Operator <br />❑ New Designated Operator <br />DESIGNATED UST OPERATOR FOR Tffi3 FACILITY: <br />PRIMARY <br />Designated Operator's Name: ZANE NIMMO Service Technician <br />Business Name: AFFORDA TEST ICC #: 5263322 -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 312/14 <br />ALTERNATEI <br />Designated Operator's Name: FELIX RAMIREZ Service Technician <br />Business Name: AFFORDA TEST ICC #: 52733934 -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br />ALTERNATE2 <br />Designated Operator's Name: <br />DAVID WINKLER <br />Service Technician <br />Business Name: <br />AFFORDA TEST <br />ICC #: 5263373 -UC <br />Designated Operator's Phone: <br />209-744-0112 <br />Expiration Date: 3/V14 <br />ALTERNATE3 <br />Designated Operator's Name: <br />LYLE NIMMO <br />Service Technician <br />Business Name: <br />AFFORDA TEST <br />ICC #: 5249115 -UC <br />Designated Operator's Phone: <br />209-744-0112 <br />Expiration Date: 3/2114 <br />I 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 <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 />W nS <br />SIGNATURE O/F' TANK OWNER: 6" <br />DATE: �/26� 2 OWNS NE: , a15-ta e <br />NOTE: <br />1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRCB) AFTER SIGNING. THE LOCAL <br />AGENCY LIST IS AVAILABLE AT: www.wakdzo-ardLcaglv_/Usttontacts/cuipa a=htmi. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br />CHANGE. <br />Uri C 'aX7-.y , -- Sc��� �� <br />