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EIVrl <br />Appendix XI <br />Underground Storage Tank MAY 2 1 2021 <br />Designated UST Operator Identification Form <br />AL <br />TYPE OF ACTION El New UST Installation New/Changed Designate61441Fci2LTH <br />FACILITY INFORMATION <br />CERS ID Facility Name <br />3-11---,(n-i=v -c_ S-Q,g_Q \ c e <br />Facility Address <br />L4015 e,, 0 A=4'\ <br />City ZIP Code <br />DESIGNATED UST OPERATOR INFORMATION <br />Print names exactly as shown on the ICC certification. <br />Name of Designated UST Operator <br />4:11-ec-, <br />ICC Certification <br />Mailing Address _ <br />V D , 'SC-,)< 105 -' <br />Phone <br />Name of Designated UST Operator <br />i1 \Q V-Y) ?---S)'r\`• <br />ICC Certification <br />,9 "Pt ,,S.---1S. <br />Mailing Address <br />-0). i.-\ (\D 0 , C. 6)15 a'3(,, <br />Phonp <br />.&eci - Ee-7 - 3(,jr"-i <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