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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 /> ce <br /> Facility Address City ZIP Code <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 /> Mailing Address Phone <br /> V . -D , l3ox 1004, L1v� p�n , Com. g4t; a3 ) o, - t 0\ � � a —► �1 <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 /> Page 1 of 1 <br />