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y = 1 <br /> 041 <br /> Appendix XI <br /> Underground Storage Tank <br /> Designated UST Operator Identification Form <br /> TYPE OF ACTION ❑ New UST Installation ❑ New/Changed Designated Operator <br /> 1 . FACILITY, INFORMATION <br /> CERS ID Facility Name <br /> 10184191 A&A GAS & FOOD MART <br /> Facility Address City ZIP Code <br /> 1330E YOSEMITE AVE [ MANTECA 95336 <br /> 2. DESIGNATED UST QPERATOR INFORMATIQN . <br /> Print names exactly as shown on the ICC certification. <br /> Name of Designated UST Operator ICC Certification <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 ICC Certification <br /> DAVID WINKLER 8883059-UC <br /> Mailing Address Phone <br /> 416 2ND STREET GALT CA 95632 209-744-0112 <br /> Name of Designated UST Operator ICC Certification <br /> FELIX RAMIREZ 883072 -UC <br /> Mailing Address Phone <br /> 416 2ND STREET GALT CA 95632 209 -744-0112 <br /> Name of Designated UST Operator ICC Certification <br /> EDWARD STEARNS 8883080 -UC <br /> Mailing Address Phone <br /> 416 2ND STREET GALT CA 95632 209444-0112 <br /> Name of De ignated UST Opera or ICC :Certificatioun <br /> 985 <br /> rn t.,� ( 41 / 35 <br /> Mailing Address <br /> �► �-1�- r PhoneYLI - 0// 2— <br /> Name of Designated UST Operator ICC Certification <br /> Mailing Address Phone <br /> Name of Designated UST Operator ICC Certification <br /> Mailing Address Phone <br /> Name of Designated UST Operator ICC Certification <br /> Mailing Address : Phone <br /> Additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council , UST = Underground Storage Tank <br /> Page 1 of 1 <br />