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RECEIVED 03122/2014 1.2:29 <br /> 0 0 RECEIVED <br /> Afforda.-Te . <br /> '416:2"'Street phone.(209)744-0112 APR 0 .2014 <br /> Mft" Galt,Ca 95632 Fax:(209)744-0116 ' E L LT <br /> afford oftcom.net <br /> Owner Statewenb of Designated Underground Storage Tank Operator DEPARTMENT <br /> and Underman#in&of and Coo !lance with UST Requirements <br /> Facility Name. Country Mart Gas&Food. Facility#: 1517 PO# <br /> Address: 3424.3 S.Chrisman Road Tracy CA 95304 Updated Owners Statement <br /> Facility Phone 4:2e 642 Change of Designated Operator <br /> 0 New Desi paled Operator <br /> S U81,OPE TOR FOR THIS l AWT <br /> PRIMARY <br /> OWSAnted Ope+atsr'a Acme: ZANE Ntl!'1MO Service T'eehnicina <br /> Business!~tame: ,AFFO)RDA TEST ICC#: 5243322-USG <br /> Designated Operator's ftone: 209-744-0112 Expiration Date: 3/3/14 <br /> ALTERNATE 1 <br /> Designated Operator's Mame: FELIX RAMIREZ Service Teebnleian <br /> Business Name: AFFORDA TEST ICC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: W3116 <br /> ,ALTERNATE 2 <br /> Designated Operator's Name., DAVID WINKLr ER Service Tedaiden <br /> Rushm/Name: ApF09DA TEST ICC#: 73-IUC <br /> ]Designated Operator's Phone: 209-744-0112 Expiration Date: 3110116 <br /> ALTERNATE3 <br /> 'gnated Opera&rlz i?smes )WWARD STEARNS Service Tectmician <br /> B sfness Name: A A TEST ICC#: 92,-IU C <br /> Deftnated Operator's Phone: 209-74,j-0112 !Expiration Date; 3,+3116 <br /> 1 ftfft*at,for the hicility indleaed at the top oi'tltis page,the individuals listed above%ill serve as i?Ps paled UST <br /> Operators, The individmats will conduct and document monthly}facility inspections and annual#'anility employee <br /> training,in <br /> Acm-daixte w:•*.}1 Califbmin Code of 23,section 2715(e)—(f). <br /> Furthermore,I Qetler td and am in complknee with the requirements(AatatM mgutations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAM$OF TANK O?WNXR(Print): �IAl <br /> SIGNATURE OF TANK 4"ER: u �-- <br /> DATE: '�- 1 -�- �� OWNERS PRONE: 2-0 js <br /> INOTr: <br /> 1)SMM W TILES CO.WLr=FORM 7U TRE LOCAL AGENCY MT SWIMB)AMR SIGNING.TB9 LOCA-, <br /> AGINCY LIST IS AV AT; tir+evr watcrtmt i egg tasifeooiactslc s htna! <br /> 2)NO}T1FY THE LOCAL AGENCY OF ANY CHANGES TO TRIS I.WPORNUTION WITHIN 30 DAYS OF TM <br /> �nAtiGib <br /> OFFICE: <br /> cbtrnty- Ct X Date Faxed; u '" Date&anted: <br /> Taste rWA211ed <br />