Laserfiche WebLink
RECEIVED BY SJC EHD (EF) ON 7/8/2021 <br /> Appendix XI <br /> Underground Storage Tank <br /> Designated UST Operator Identification Form <br /> TYPE OF ACTION ❑ New UST Installation N New/Changed Designated Operator <br /> 1. FACILITY INFORMATION <br /> CERS ID Facilit Name <br /> I41� �513 �OLICTON U'NIl�1� <br /> Facility Address I City ZIP Code <br /> STO �( C1 r) 2 0 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Print names exactly as shown on the ICC certification. <br /> Name of Designated UST Operator ICC Certification <br /> GREG KAISER 5252318 <br /> Mailing Address Phone <br /> PO BOX 1058, LINDEN, CA 95236 209) 887-2639 <br /> Name of Designated UST Operator ECC Certifi ation <br /> STEPHANIE MURPHY 9383552 <br /> Mailing Address Phone <br /> PO BOX 1058, LINDEN, CA 95236 (209 887-2639 <br /> Name of Designated UST Operator; , ICC Certification <br /> MARISSA MURPHY 9715874 Z IO f Zz ti'L <br /> Mailing Address Phone <br /> PO BOX 1058, LINDEN, CA 95236 (209) 887-2639 <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 T ICC Certification <br /> Mailing Address Phone <br /> Name of Designated UST Operator ICC Certification <br /> Mailing Address J 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 />