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;Dr4-Te9t 1 416 2-11' Street Phone: (299) 744-0112 <br />Gjklt, Ca 95632 Fax-, � 744-0116 <br />Owner, Statements of ]Designated Uoderground Storage Tank Opemtor <br />and Understanding of and Compliance with UST Requirements <br />Facility Nglne,. Cyupe Commercial Company Facility 4 -- <br />Acidness; 5000: S Lindbergh St Gate 16 Stocktqn CA 95206 <br />Vaeflity Phone'#- 13ltdikte Of DefWSfed Opmar <br />New n4-,A-ate4 Oiwrmor <br />DESIGNAXE—D, UST QUL&AJOR FOR THIS TA <br />PRIMARY <br />Oqignattd Operator's Name: WE NINW Service Technician <br />business Nr >ne:, AFFOROA TEST ICC #. ,6332,-U. RECEIVED <br />Demelated0peratQT's Plione, 20-7444112 Rxplmt14Aj)ste: 3/3116 <br />ALTERNATEI <br />FELMRAMIREZ <br />Business Nxmm AFFORDA TEST <br />Designated Opernforl0hane:- 209-744-113I2 <br />ALTERNATE <br />)DALVIDWETKLER <br />A"ORDATEST <br />Designated Operator's imine: <br />ALTEMATE3 <br />0g2AgnatcdOpemtW,s11Vxmc.. ZDWARD,6TRAkM <br />Sqsfiaess Nanxg: "PORDATEST <br />Designated Opamwrls rizone, 209 -744 -OW <br />APR 0 71,204, <br />Service Techaidw, <br />ICC 9. P733934,'UC C: <br />&Virafion Da=.313nj-NVI RON MENTAL HEA <br />DEPARTMENT <br />Soxvlee Teardelan <br />ICC A 52633734JC <br />EXPIrA00A 00e., 3110116. <br />rE <br />:Service Techniela <br />JCC A 52,"02 -'LIC <br />Expiration date: 3/3?16 <br />,I terfify that, for the focility. indieRted gttha top of this pop, the individuals listed above will save as Designated VST A <br />Operators. Tht individuals will conduct and, document monthly facility iospectlons; and aonval, &cift employee <br />trat ' ningo in <br />ActordRned Whit California Code afRegul-ati0s, title 23, section 2715 (e) <br />Furthermore, I understand and am in covoplianee with the r¢qujrements (statutes, rWistions, and 1041 <br />Ordinances) applicahkto underground storage tanks, <br />NA -ME OF TANK OWNER. (Print): <br />SIGINATUREOF TANK OWKER- <br />JDATE-. 1-7 )) � <br />�7-M)1�,(aUmejtW 6ovi <br />0"ERS PHONE.* <br />NOTE- i) SUBMIT TIRTS COWLETED-FORMTO TRE LOCAL AGENCY (NOT SWRCA) AIZTAR SIGMG. TJM LOCAL <br />A,00(CY LJ517 Is AVAILABLE AT. A&J&Wj$ <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS WFORMATION W)rrMN -30 DAYS 00 T14E <br />CHANGE. <br />OFAvICE. 4b, [L <br />County: �ZC Date.Faxed: 14 If Date Scanaed;.... -4 <br />Date E-Malled <br />