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FEB / 25/ 2022 / FRI 04 . 06 PM Tracy Truck Stop FAX No , 209832 2312 P3009
<br /> Appendix XI
<br /> Underground Storage Tank
<br /> Designated UST Operator Identification Form
<br /> TYPE OF ACTION ❑ New UST installation [� New/Changed Designated Operator
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<br /> Facility Name
<br /> 10187337 CD R TRACY BOULEVARD CHEVRON
<br /> Facility Address
<br /> Ci ZIP Code
<br /> MINE 3 111 775 WE TIII R11 ACY III BLVD Y 95376
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<br /> Print names exactly as shown on the ICC certification,
<br /> Name of Designated UST Operator ICC Certification
<br /> David Winkler 8883059 -UC
<br /> Mailing Address Phone
<br /> 416 2nd Street Gait, CA 95632 209-744-0112
<br /> Name of Designated UST Operator ICC Certification
<br /> Zane Nimmo 8883064-UC
<br /> Mailing Address Phone
<br /> 416 2nd Street Galt, CA 95632 209 -744-0112
<br /> Name of Designated UST Operator ICC Certification
<br /> Felix Ramirez 8883072-UC
<br /> Mailing Address
<br /> 416 2nd Street Galt, CA 95632 Phone
<br /> Phone209J44-0112
<br /> Name of Designated UST Operator ICC Certification
<br /> Edward Stearns 8883080 -UC
<br /> Mailing Address Phone
<br /> 416 2nd Street Gait, CA 95632 209 ,7440112
<br /> Name of Designated UST Operator ICC Certification
<br /> Amy Winkler 9951352- UC
<br /> Mailing Address Phone
<br /> 416 2nd Street Galt, CA 95632 209-712-0112
<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 /> Received Time Feb , 25 . 2022 4104PM No , 7114
<br /> • Page 1 of 1
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