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C.E.S. California Enviromental Services <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: (.00A n-I r �q G"' Facility M*: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> / 7 S'c( C (r ` s TOC-i.!re N 91—Choose of Designated Operator <br /> Facility Phone=: Z G cf 3 70 3 50 $ ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: Thomas Lee Hingston Relation to UST Facility(Check One) <br /> Business Name(Ifdyerentfrom above): C.E.S. I ❑ Owner ❑ Operate: ❑ Emplo}•cc <br /> Designated Operator's Phone 707-987-4770 I ❑ Service Technician `D` Third-Party <br /> Intemational Code Council Certification m: 5c `7'3 77 SS '0C I Expiration Data: 16-- p -2-6C6 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Narne: Gabrial Urrea Relation to UST Facility(Check One) I <br /> Business Name(Ifdrfferentfrom above): C.E.S. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone- 916-727-2773 ❑ Service Technician IR Third-Party <br /> International Code Council Certification r: Emiration Dat: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Michial Kidd Relation to UST Facility(Check One) <br /> Business Name Qfdlfferentfrom above): C.E.S. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 1: 916-296-2283 I ❑ Semcc Technician q Thirst-Pam <br /> International Code Council Certification m: EaTiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) -(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER �-<1. r <br /> O OWNER'S AGEN lease Print) I r lC. i� h- [ {� Q����CS <br /> SIGNATURE OF T41 �_ ��� T>CZb9 <br /> OWNER OR WNER'S AGE Le�.c-� <br /> DATE: l�/lo �O•X OWNER'S PHONEcC 70 �S O <br /> September 2004 <br />