Laserfiche WebLink
Dec 23 04 11 : 48a rnichael kidd 209-257-1978 p. 2 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityName: (/��Jk/!/1 ) �% MIMI mp117- Facility ID#: <br /> Facility Address: hl W11 $3 Reason for Submitting this Form(Check One) <br /> 1110 d: Change of Designated Operator <br /> I acility Phone#: a J� -� a ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY Relation w UST Facility(Cheat One) <br /> DesignawdOperstor'sName:Tbomas Lee Hin stun <br /> Business Name(If differentfrow above): C.E-S ❑ Owner O Operator Q Employee <br /> k ❑ Service Technician 'f] Third-Party <br /> Designated Operator's Phone#: 707-987-4770 'R <br /> International Code Council Certification#: 5 24 377 8-V C Expiration Date:10/0 8/06 <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name:Mi C h a e 1 B. Kidd Relation to UST Facility(Check One) <br /> Business Name(If d&renjfrom above): C.E-S- ❑ Owner Q Operator ❑ Employee <br /> Designated Operator's Phone#:916-2 9 6-2 2 8 3 O Service Technician "Rt Third-Party <br /> International Code Council Certification#: 5Z11 6 ZL(3"' U C Expiration Date: 1112,2106' <br /> .ALTERNATE 2 (Optional) <br /> Designated Operator's Name:Gabr i a 1 Ur r ea Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent front above): C.E.S. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:916-7 2 7-2 7 7 3 ❑ Service Technician J(l Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> jI certify that, for the facility indicated at the top of this page,the individual(s)listed above will <br /> t 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 27I5(c) -(f}_ <br /> i <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 <br /> OR OWNER's AGENT(Please]Print): CGVW/t <br /> SIGNATURE OF TANK ��S <br /> OWNER OR OWNER'S AGENT:—Ak � <br /> DATE \�\04A OWNER'S PHONE#: 2 3bd_�s3�0 <br /> Sentetnber 2004 <br />