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RECEI <br /> VED <br /> APR 07 2014 <br /> 416'2"'Street Phone.(20)744-0112 <br /> A.11,orda-Te <br /> Gait,Ca 95632 Fax..M9)7 16 <br /> affe m. et <br /> ENVIRON44E+1TAL HEALTH <br /> owner Statemenu dDesipated Untie on Storage Task Operator DEPARTMENT <br /> and Uaderstawling of and Co%pliance witb UST u" is <br /> taeft Naime' Gravmls Gas&Liquor Fift ity <br /> '�doresq: 4100 E Fremont ft"ktQ0 CA W Updated Owners sw6fitent N, <br /> Cbaw of Deftanted optrow <br /> 'Phone 2094Q-=4 <br /> New Mgnsled Orrgwr <br /> HATED Ila O_PERATOREgR TIM IAMI=-. <br /> ftINARY <br /> iqsqcd Opuatees Name- ZANE NIMMO Service Technician <br /> #.. szM <br /> lBaduess Name: AFFORIDA TEST ICC 22-1JC <br /> Expiratiop Date. 313/16 <br /> �aigftted OpergWep Phone. 7.09-744-0112 <br /> 1ALTERNATEI Service Tathilleian <br /> Name: FELJX RAMIREZ Icc# s27&"34-UC <br /> 113nslnen Name: Af .FortDATEST Expiration Date: 313/16 <br /> j11C5jlputed Oomtors none: 209-744-011'2 <br /> 1ALTERNATE 2 <br /> Se Technidan <br /> IDesigNSW Opentgr1a,Name. DAVWWTNKLER <br /> i ICC a: 5263313-UC <br /> iguitineo Name* AFFOP.JDATBST <br /> Expiration Date; 3fl&16 <br /> jDt�jgpffjad Operator's Phone: W9-744-0112 <br /> jAL;,rVkNATE 3 <br /> service Technician <br /> ARD SrEA)INS <br /> Dejignated Operator%Name. BOW Ecc ft 52W92-UC <br /> i Oak""Name® AFTOWDA TEST <br /> Exp^Kratim Date. W31 <br /> Designated Opamtor's PhORM 2W744-0112 <br /> m+o <br /> I cer"Y tMt,for the fvAllity Indicated at the top of this pme,the indiviindividualsw;listed above It as Daigna ted'U 5T <br /> monoly facility ingpedioas and annual 11scility emploYat <br /> Operators, The individuals Will onduo and document <br /> training,io <br /> Acordance With California Code of 14610ons,title a sation.2715 W-(06 <br /> irtirthermore,I underSUnd said am in compliance with the reguiremelits(040"regulations.and 100*1 <br /> oro(Aantes) applicable to und4rgroond storage tanks- <br /> NAME OF TANK OWNER/0PONtOr(Print): <br /> SIGNATURE 01F TANr.OWNER/Opmtor <br /> 297 <br /> 1 NOTE, SIGKr4G.THE LOCAL <br /> 8,08Mrr TRW,ComMMID roam TO THE LOCAL A10ENCY(NOT SWV9A)AFTER <br /> AGENCY LIST IS AVAX"BLE AT: !ue leonmewkly -W <br /> 2) 74(MIFYTHF WCAL AGSNCY OF AN TOTHIS trrFORhtATM WITHIN 30]DAY$OF THE <br /> 6ANGE. <br /> OF1110E- <br /> County. ��C- Date Scanned. <br /> Date E-Mailed <br /> J <br /> OT:91 VTBUET/60 CE AMM <br />