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Appendix XI <br /> Underground Storage Tank <br /> Designated UST Operator Identification Form <br /> TYPE OF ACTION Lj New UST Installation -Li New/Changed Designated Operator <br /> 1. FACILITY INFORMATION <br /> CERS ID Facility Name <br /> t o'17 6 64Q i4l <br /> Facility Address City ZIP Code 11 ('Oto EL <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Print names exactly as shown on the ICC certification. <br /> ►') k-:E a,) A R N P 12-- <br /> Name of Designated UST Operator ICC Certification <br /> Mailing Address Phone <br /> go N - 2 t✓o a CSA 9��`� <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 /> 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 /> 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 />