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fforda <br />"I .R st 1436 "Street Phone: (209) 744-0112 <br />Gait, Ca 95632 Fax: (209) 744.0116 <br />affords fiiGcont.net <br />er Statemetais of Designated Underground Storage Tank Opetrator <br />and Undexstand3ing of and Compliance with UST Requirements <br />Facflity Name: Rai - 5b&k� kntx, `acilitty #s tp - to <br />Address: 3Zz s: C�r�--der° 5--k Gi'c �t5Zi�3 <br />F'aci Zty Phone #: .Z�R4 (a H 35 ® Ckattge Of Dw4zaated operawr <br />�^�'(�T ew beftaxt4 Operate, <br />k1°i.+�7A�NATR'ifi lJ.�A t-WVVID An 'i:wr^ S �1 Z ° <br />MARY <br />13ce'grtated Opsrater's NRt1te: ZATi JE NiMlYIQ Service Teehrriciat AN <br />susineft Marne. AMRDA TEST <br />Desigaatcd Operattoes Phonc: 7.09.744-01 j- <br />0"'gnatcd Operator's Names FELIX RAMtic9Z <br />BuenewNmnc; APFORDA TEST <br />DCS18nat0d Operatcr'a Phone: 209-744-0112 <br />Designated •. p <br />Busing NW= <br />Designated Operator's Phone,; <br />ALTERNATE 3 <br />Designated Open Imes Name: <br />Bu$in= Name: <br />Dccignated Operxtor's Phone: <br />AFFORDA TEST <br />209.744.0112 <br />LYLle e O <br />AFI' ORDA TEST <br />209-744-0112 <br />ICC 4: $263322 -UC <br />i xpuat 0n Dwe. 3/2/12 <br />Service Technician <br />ICC 4: 52733934-t7C <br />Expirnzion Date: 4/7/12 <br />Service Technician <br />ICC#: 5263373-t7C <br />Expimtion Date: 344/12 <br />Ssrvicc Technician <br />ICC;9; 5249115 -UC <br />Expiration Date: 2/24/12 <br />I ccrdfy that, fpr the facility indicated at the tap ofthis page, the individuals Ii�ed above will serve as Dcsigtutted UST <br />Oparators The individuals will conduct and document monthly facility inspections and annual facility empfoyec training, in <br />Accattifancx with California Corte of Regiriations, title 23, Section 2715 <br />7 f 5 (c) — (t), <br />Furthermore, I ua?derstand end amram in compliance with the regv4renments (10tutL% regulations, and local <br />Ordinattees) applicable to underground storage tanks. <br />NAME OF TANK O (Print): /1��j— j <br />STGNAT1W OF TANK OWnit: <br />:I1/1/i0 <br />NO'1�'O RS PHONE: <br />OTE: ; <br />1) SUBMIT THIS I.;tiDv FORM ,TtO T146 t OGAILIST IS AVAILAELE AT: 'AGENCY (NOT SWFtCB) AFTR SIGNTNG. TKE LOCAL AGENCY <br />�•�,u1u�/ <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITfUN 30 DAYS OF TNF CI1ANpE. <br />OFFI :�: \\ <br />Cotpnty. L3 ; Rate Faxed- Date Scanned. <br />` 1�.:1st.:�a,._ is �d iD <br />1 <br />T000/T0001A XH,3 99:60 ZTOZ/60/TO <br />