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06 / 28 / 2019 19 : 29 8387674 EMILS PAGE 25 <br /> Ut phi GR'�UND STbRA0tTAN ,K . ' <br /> CESIGN>4T U U,NU RGROUND STORAGE TANK OPEPATOF iQEN?iFICATION FORM (pag$, 1 • os 1 ) <br /> Every underground storage tank (UST) facility must have at loads one deeignewo U $T operator_ A copy of this completed form must be <br /> uivalent local Unitled Program Agenc <br /> electronically auhmittad via either the CalHomia Environmental Reporting System (CERS) or an eqy ss <br /> f the UST; or 3) an addition or <br /> electronic reporting portal within 3e days of: 1 ) an Installation of a UST; 2) a change in owner or operator oi <br /> change of an individual performing deatgnated UST operator inspections or facility employae training at this facility. (Calitornia Code of i <br /> Regulations, Title 2 3 , Division 3, Cnapter 16, 84ctlon 2716(a).j l <br /> Type of Action 0 New UST installation~ C1 Change of Owner or Operator DO New or Change of Derrignaled UST Operator <br /> •. :; , <br /> • •, , .• • • • . ,.: . . ., 1, FACILITY INFORNLATtC?N i <br /> Business Name (Same as Facility Name or DBA-Doing Business As) I CERS ID <br /> Emils Liquor & Sport Shop , 10180567 <br /> Business Site Address FEscalon <br /> y Zip Code <br /> 1405 California Street 95320 <br /> The Individual(a) Hsted below will conduct and document the facility inspections and facility employee training for the facility Hated ebow In i <br /> accordance with California Cods of Rogutstiona, Title 23, Division 3, Chapter 16, $eetione 2718(c) and 2716 . i <br /> �QNATWUNl3ER'aRO.UND. STQ AGR::LALWOPERATORS INFORMO> TION <br /> Name of Designated UST Operator (Print as shown an the 1CC certification.) IGC Certification # <br /> Z 8863064-UC <br /> Zane Nimmo <br /> Mailing Address ~� Phone # <br /> 416 2nd Street GALT CA 95632 (209 ) 744 . 0112 <br /> Name of Designated UST Operator (Print as shown on the ICC car0cation.) ICC Certification 9 <br /> David Winkler 8883059-UC <br /> Mailing Aderess Phone # <br /> 416 2nd Street GALT CA 95632 (209 ) 744- 01, 12 <br /> Name of Designated U$T Operator (Print as shown on the ICC certification) ICC Certification 8 <br /> Felix Ramirez 8883072- UC <br /> Mailing Aderess Phone # <br /> 416 2nd Street GALT CA 95632 (209 ) X44-0112 <br /> 14 Name of Designated UST Operator (Print as shown on the fCC certification.) ICC Certification # <br /> Edward Steams 7:18883080-UC <br /> Meiling 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.) 1CC certification # <br /> Mailing Address Phone ;g <br /> Name of Designated UST Operator (Print as shown on the /CC cerdflodtion.) ICC Certification # <br /> Mailing Address Phone tR <br /> Name of Designated UST Operator (Print as shown on the /CC certitic®don.) ICC Certificaoon # <br /> Maliing Address PhO # <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ) GC Certification # <br /> Mailing Address Phone # <br /> Name of De. ignatad UST Operator (Print as shown on the /CC conlilcation.) ICC C6rtlficallon # <br /> Malting Address <br /> Name of Designated UST Operator (Print as shown on the ICC certification) IC.O Certification # <br /> Mailing Address Phone # <br /> Attach additions( page(s) containing all the Information in section It if more alternates are used. <br /> ID = lderrtiara . ICC ;; h"(WIalia'el Code ..ot,rd <br /> Received Time Jun , 28 , 2019 7127PM No , 5223 <br />