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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 ❑x 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 <br /> Tracy Shell 10181411 <br /> Business Site Address City ZIP Code <br /> 3725 N. Tracy Blvd Tracy 95376 <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 /> Kris Bell 8833000 <br /> Mailing Address =408)680 Quinn Ave.San Jose,Ca 95112 971-2445 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Brian McPheeley 8822062 <br /> Mailing Address =408)680 Quinn Ave.San Jose,Ca 95112 971-2445 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Maria Guarnelli 8158671 <br /> Mailing Address =408) <br /> 680 Quinn Ave.San Jose,Ca 95112 971-2445 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Deborah Ward 8818688 <br /> Mailing Address =408) <br /> 680 Quinn Ave.San Jose,Ca 95112 971-2445 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Theodore Van Bebber 8868021 <br /> Mailing Address =(408) <br /> 680 Quinn Ave.San Jose,Ca 95112 971-2445 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Samantha McMahan 8950093 <br /> Mailing Address Phone# <br /> 680 Quinn Ave.San Jose,Ca 95112 (408)971-2445 <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 /> 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=International Code Council <br />