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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR IDENTIFICATION FORM (Page 1 of 1 ) i <br /> Evory underground storage tank (UST) facility must have at least one designated UST operator. A copy of this completed form must be <br /> electronically submitted via either the California Environmental Reporting System (CERS) or an equivalent local Unified Program Agency <br /> electronic reporting portal within 30 days of: 1) an Installation of a UST; 2) a change in owner or operator of the UST; or 3) an addition or <br /> change of an Individual performing designated UST operator Inspections or facility employee training at this facility. [California Code of <br /> Regulations, Title 23, Division 3, Chapter 16, Section 2716(0)61 <br /> Type of Action p New UST Installation p Change of Owner or Operator (W Now or Change of Designated UST Operator <br /> 1 . FACILITY INFORMATION <br /> Business Name (Same as FacifilyName orDBA•0o1hg Business As) CERS 1D <br /> Sutter Health Tracy 10397699 <br /> Business Site Address City ZIP Code <br /> 1420 North Tracy Boulevard Tracy 195376 M <br /> The Individual(s) listed below will conduct and document the facility Inspections and facility employee training for the facility listed above In <br /> aocordancewith California Code of Regulations, Title 23, Division 3, Chapter 16, Sections 2716(c) and 2716. <br /> IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR(S ) INFORMATION <br /> Name of Designated UST Operator (Print as shown on Lite ICC cerfificaflon) ICC Certification # l <br /> Zane Nimmo 8883064- UC <br /> Mailing Address Phone # <br /> 416 2nd Street GALT CA 95632 (209) 744 -0112 <br /> Name of Designated UST Operator (Print as shown on the ICC certiticafion.) [CC Certification # <br /> David Winkler 8883059•UC <br /> Mal►ing Address Phone # <br /> 416 2nd Street GALT CA 95632 (208) 744 -0112 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) too Certification # <br /> Felix Ramirez 8883072- UC <br /> Mailing Address Phone # <br /> 416 2nd Street GALT CA 95632 (209) 744 -0112 <br /> Name of Designated UST Operator (Print as shown on the iCC certilkefton.) ICC Certification # <br /> Edward Stearns 8883080-UC <br /> Mailing Address Phone # <br /> 416 2nd Street GALT CA 95632 (209) 744 0112 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) [CC Ceriigcalton # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC cerlilkation.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certirication.) ICC Certification # <br /> Mailing Address Phone # <br /> I <br /> Name of Designated UST Operator (Print as shown on the 10C certilkation) ICG Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the JCC certllfcatlon.) ICC Certiticallon # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the iCC cortfikallon.) ICC Certification # <br /> Mailing Address Phone # <br /> Attach additional pages) containing all the information in section 11 It more alternates are used. <br /> IDR IdendlicaM ICC n In wWonaf Code Coundi <br /> 1 <br />