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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR IDENTIFICATION FORM (Page 1 of 1 ) <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 2715(a).] <br /> Type of Action <br /> ❑ New UST Installation El 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 ID c <br /> Business Site Address City ZIP Code <br /> ti <br /> Ito F: !1 �C I l 11 1V ST °`�' 13 <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 /> IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR(S) INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> James Williams 5252274-UC Exp . 3/25/21 <br /> Mailing Address Phone # <br /> BZ Service Station Maintenance , Inc , PO Box 933 , West Sacramento , Ca 95691 (916) 371 -2380 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Ron Anton 9052121 UC Exp 10/ 15/21 <br /> Mailing Address Phone # <br /> BZ Service Station Maintenance , Inc , PO Box 933 , West Sacramento , Ca 95691 (916 ) 371 -2380 <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 certification.) ICC Certification # <br /> Paul Godwin 8820101 -UC Exp . 11 / 17/21 <br /> Mailing Address Phone # <br /> BZ Service Station Maintenance , Inc , PO Box 933 , West Sacramento , Ca 95691 (916 ) 371 -2380 <br /> Name of Designated UST Operator (Print as shown on the /CC certification.) ICC Certification # <br /> Rhome Desbiens 5244364- UC Exp . 1 /23/20 <br /> Mailing Address Phone # <br /> BZ Service Station Maintenance , Inc, PO Box 933 , West Sacramento , Ca 95691 (916) 371 -2380 <br /> Name of Designated UST Operator (Print as shown on the /CC certification.) ICC Certification # <br /> Jeramy Cummins 8019661 - UC Exp . 9/27/20 <br /> Mailing Address Phone # <br /> BZ Service Station Maintenance , Inc, PO Box 933 , West Sacramento , Ca 95691 (916 ) 371 -2380 <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 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 /> Attach additional page(s) containing all the information in section 11 if more alternates are used. <br /> ID = Identification, ICC = Intemational Code Council <br />