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Nov 16 05 08:27a Tomo <br />Cston 707-987-4682 p.2 <br />FRECOWED C�� <br />CALIFDRNIA <br />C.E.S. California Environmental Services NOV 1 7 X005 <br />ENVIRONMENT HEALTH <br />Owner Statements of Designated UndergroundQW-MR- UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name;]�7 <br />Facility ID #: <br />Facility Address: <br />� cl�•y Y cf <br />Reason for Submitting this Form (Check One) <br />Designated Operator's Phone #: 707-987-4770 <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 1 v 9 <br />Designated UST Operator(s) for this Fatality <br />PRIMARY <br />Designated Operator's Name: <br />Thomas Lee Hingston <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician M Third -Party <br />Business Name (lf dierentfrwn above): C.E.S. <br />Designated Operator's Phone #: 707-987-4770 <br />International Code Council Certification #: <br />5243778 -UC <br />Expiration Date: 10-06-2006 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Thomas Dee Hingston II <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician M Third -Party <br />Business Name"(Ifdierentfrom above): C.E.S. <br />Designated Operator's Phone #: 707-987-4770 <br />International Code Council Certification #: <br />5253130 -UC <br />Expiration Date: 01-03-2007 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Gabrial Urrea <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician GO Third -Party <br />Business Name (lfdierent from ahove): C.E.S <br />Designated Operator's Phone #: 916-296-2283 <br />International Code Council Certification #: <br />5246243 -UC <br />Expiration Date: 1 ]-06-2006 <br />ALTERNATE 3 (Optional) <br />Designated Operator's Name: <br />Michael Kidd <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Q Third -Party <br />Business Name (If different from above): C.E.S <br />Designated Operator's Phone #: 916-296-2283 <br />International Code Council Certification #: <br />5246243 -UC <br />Expiration Date: 11-22-2006 <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated <br />UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility <br />employee training, in accordance with California Code of Regulations, title 23. section 2715(c) - (fl. <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br />ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER OR OWNER'S AGENT (Please Print): <br />SIGNATURE OF TANK OWNER OR OWNER'S AGENT: <br />DATE: /U `�/ " 6 J OWNER'S PHONE #:d 7j_ <br />� #:W/Z. / yT <br />LOCAL AGENCY OF ANY CHANGES TO THIS <br />ATION WITHIN 30 DAYS OF THE CHANCE <br />It�2°alOv <br />