Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR IDENTIFICATION FORM (Page 1 of I ) <br /> Every 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(a).] <br /> Type of Action <br /> ❑ New UST Installation F1 Change of Owner or Operator ❑ New or Change of Designated UST Operator <br /> In FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Business Site Address City ZIP Code <br /> The individual(s) listed below will conduct and document the facility inspections and facility employee training for the facility listed above in <br /> accordance with California Code of Regulations, Title 23 , Division 3, Chapter 16, Sections 2716(c) and 2716 . <br /> 11 . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR S) INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC cert cation.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certification) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certification) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certification) ICC Certification # <br /> i <br /> I <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the /CC certification.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC cert cation) ICC Certification # <br /> Mailing Address Phone # <br /> Attach additional page(s) containing all the information in section it if more alternates are used. <br /> ID = Identification, ICC = International Code Council <br /> UN-062 www, unidocs .org 1h - Rev. 06/14/18 <br />