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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 /> 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 /> James Williams 5252274-UC 2-17-2023 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <br /> Name of Designated UST Operator ICC Certification <br /> Ron Anton 9052121-UC 11/20/23 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <br /> Name of Designated UST Operator ICC Certification <br /> Levi Temple 9608566 - UC 11-18-2022 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <br /> Name of Designated UST Operator ICC Certification <br /> Rhome Desbiens _ 5244364-UC 12/29/21 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <br /> Name of Designated UST Operator ICC Certification <br /> Jeramy Cummins 8019661-UC 9/17/22 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <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 />