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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR IDENTIFICATION FORM (Page 1 oft) <br /> Every underground storage tank (LIST)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 2715(a).] <br /> Type of Action <br /> ❑ New UST Installation ❑Change of Owner or Operator New or Change of Designated UST Operator <br /> I. FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS I D <br /> Lodi CA FO Term (Intl) 10403278 <br /> Business Site Address City ZIP Code <br /> 2500 West Turner Road Lodi 95242 <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 2715(c)and 2716. <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR(S) INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Leonardo Aguilar 5302718 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888)588-8737 <br /> Name of Designated UST Operator(Print as shown on the/CC certification.) ICC Certification# <br /> Ruben Becerra 5302139 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888)588-8737 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Brandon Bowers 8890689 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888)588-8737 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Tyler Davidson 8841977 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino, CA 91710 (888)588-8737 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Todd Hansen 8045710 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888) 588-8737 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Krai2 Kinder 8296393 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888) 588-8737 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Spencer Kissick 8169987 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888) 588-8737 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Al Queiros 5053226 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888) 588-8737 <br /> ICC Certification# <br /> Name of Designated UST Operator(Print as shown on the/CC certification.) <br /> Megan Sward 8917153 <br /> Mailing Address Phone# <br /> 4780 Cheyenne Way,Chino,CA 91710 (888)588-8737 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Mailing Address Phone# August 29,2019 9:46:57 am <br /> Attach additional page(s) containing all the information in section 11 if more alternates are used. <br /> ID=Identification,ICC=International Cade Coundl <br />