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04/30/2012 12:35 FAX <br /> ,.�' a ,_ [�)0001/0001 <br /> Phone:(tag)7a4-0112;, 201 <br /> ��■1 {A P 416 2nd Street .Fax:(209)744-0116 <br /> ~ i®A a—T SI Gait,Ca ( 6� '_.' at s <br /> afforda oftcom-net �p,Ac-F lir ICAa � <br /> ound Storage Tank®Perator <br /> c ;n <br /> ated Undergr uirelnents <br /> Owner Statements <br /> of Dom `ompuance with UST Req <br /> and Understanding Facility#: 1205 <br /> Facility Name: Grewds Gas UPDATE of Designated Operator <br /> Address: 4100 E Fremont St Stockton CA <br /> Facility <br /> Phone#:209-463-5294 Q Designated operator <br /> TOR <br /> UFOR THIS FACILE <br /> DESIGNATED ST OPERA <br /> Service Technician <br /> PRIMARY ZANE NIMMO <br /> Designated Operator's Name: ICC#: 5263322-UC <br /> ST <br /> Business Mame: <br /> A.FFORDA TEExpiration Date: 3!2/14 <br /> Designated operator's Phone: 209-744-0112 <br /> ALTERNATE 1 Service Technician <br /> Designated Operator's Name: FELIX RAMTREE <br /> ICC#: 52733934--Z3C <br /> Business Name: AFFORDA TEST <br /> Expiration Date: 3tZl14 <br /> Designated Operator's Phone: 209-744-0112 <br /> �,,'rE ATE 2 <br /> Service Technician <br /> W ER ICC#: UC <br /> Designated Operator's Name: AFrFORDA TEST <br /> Business Name: Expiration Date: 3!2!14 <br /> Designated operator's Phone: 209-7"-0112 <br /> ALTERNATE 3 Service Technician <br /> Designated Operator's Name: LYLE NIMMO <br /> ICC#: 5M115-UC <br /> Business Name: AFFOR.DA TEST <br /> Expiration Date. 32114 . <br /> Designated Operator's Phone: 209-744-0112 <br /> I certify that,for the facility indicated at the top of thmonthtye�the ifacil t2/nispections and annuals listed above facilityfacl serve ility employeeU� <br /> Operators. The individuals will conduct and document <br /> training,in <br /> of Regulations,title 23,section 2715(c)—( - <br /> Accordance with California Code compliance with the requirements(statutes,regulations,and local <br /> Furthermore,I understand and am in <br /> Ordinances) applicable to underground storage tanks. ��- ,C-- �'�YG W'd <br /> NAME OF TANK OWNER(P'r'int): <br /> SIGNATURE OF TANK OWNER: <br /> / <br /> DATE. `7r "Z//?" I O� PHONE: <br /> AFTER 1) <br /> THE LOCAL <br /> NOTE: <br /> 1} SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT&WRCB) <br /> AGENCY LISP IS AVAILABLE AT: www wa er ard!- vlusdcontactsJcnua agvs.htmt. 30 DAYS OF THE <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WTTHIN <br /> CHANGE. ` <br /> OFFICE: L� Date Faxed: !2 Date Scanned: 4.;/ <br /> County: -• <br />