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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 New UST Installation ❑ Change of Owner or Operator 0 New or Change of Designated UST Operator <br /> 1 . FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Hammer/1 =5 Sinclair 10180825 <br /> Business Site Address City ZIP Code <br /> 3250 W . Hammer Lane Stockton 195209 <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 /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATORS INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Wesley Parkinson 10139634 <br /> Mailing Address Phone # <br /> 3250 W. Hammer Lane Stockton , CA 95209 (209 ) 6624452 <br /> Name of Designated UST Operator (Print as shown on the iCC certificallon.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the ICC certificallon.) 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 /> 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 tha iCC certillcation.) ICC Certification # <br /> Mailing Address Phone # <br /> Name of Designated UST Operator (Print as shown on the iCC camcation.) 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 it If more alternates are used. <br /> ID = Identification, ICC = lnternabonal Code Council <br />