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Nov, 14, 2618 4:3OPM No. 2487 P. 5 <br /> UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK..OPERATOR IDENTIFICATION FORM.(Pasg1 of , <br /> Every underground storage tank(US7)facility roust have at least one designated UST operator. A copy of this completed fort must be <br /> electronically submitted via either the California Environmental Reporting System(CERS)or an equivalent local Unitled Program <br /> t Agency <br /> electronic reporting portal within 30 days of:1)an installation 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 faollity employee training at this facility.(California Code of <br /> Regulations,lit,23,div.3,ch.10,§2715 a. <br /> T e of Action ❑New UST installation ®Chan a of Owner or Operator ❑New or Chane of Designated UST Operator. <br /> 1. 'I:ACILiTY INFORMATION <br /> Business Name(Same as Facility Name or ODA-Doing BUSlnes$A .) CERS IDI <br /> A 11 tJW l� <br /> Business to dress City YIP Code <br /> ;7 57' -Pa 1 <br /> s <br /> The Indlvldual(s)listed below will conduct and document the facility inspections and facility employee training,for the facility listed above,I <br /> accordance with California Code of Regulations,title 23,division 3,chapter 16 sections 2716(c)and 2716, <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATORS INFORMATION, <br /> Nagle-01Nagle-01 Designated UST Oper rint as shown on the iCG cerfifrcalion.) ICC Certification# <br /> in duress Phone# / <br /> A. <br /> Name of Designated UST Operator( tint as shown odthe ICC certffkation,) ICC Certification# <br /> Mailing Address AtGEI <br /> Name of Designated UST Operator(Prfnt as shown on the ICC cerftatlon.) ICC Certification# <br /> NOV 201 <br /> Mailing Address Phone# <br /> t <br /> Name of Designated UST Operator(print as shown on the ICC ooditioetlon) ICC Cerlifica . .FIN ' <br /> Mailing Address Phone# <br /> } - Ext. <br /> Name of Designated UST Operator(Print as shown on the ICC certlt elfon) IGC Certification# <br /> Mailing Address Phone# <br /> } - Ext. <br /> Name of Designated UST Operator(Prfnf as shown on the ICG certifkation.) ICC Certification# <br /> Mailing Address Phone# <br /> } - Ext. <br /> Name of Designated UST Operator(Print as shown on the IGC certiNkation.) iCC Codification# <br /> Mailing Address Phone# <br /> ( ) - Ext. <br /> Name of Designated UST Operator(Pdlnl es shown on the ICC oer(ilkation.) ICC°Cerlificalion# <br /> Mailing Address Phone# <br /> ( ) - Ext. <br /> Name of Designated UST Operator(Print as shown on the iCC certification.) IGC Certification# <br /> Mailing Address Phone®# <br /> ! - Etrt- <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) ICC Certification# <br /> Mailing Address Phone# <br /> } - Ext, <br /> Attach addlilonaf pages)contoInIng all the Information fn sectfon If lfmore elf amates are used. <br /> CERS a California Environmental Reporting Systems,10 a Identification,ICC=International Code Council <br />