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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 /> Adam Smitheram 9084899 <br /> Mailing Address Phone <br /> 4901 Warehouse Way, Sacramento, CA 95826 916-704-6948 <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 />