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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).j <br /> Type of Action 0 New UST Installation ❑ Change of Owner or Operator 0 New or Change of Designated UST Operator <br /> I . FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br /> CANEPAS CAR WASH 10182251 <br /> Business Site Address City ZIP Code <br /> 6230 PACIFIC AVENUE STOCKTON 95207 <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 /> II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR(S) INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Zane Nimmo �7 8883064- UC <br /> Mailing Address Phone # <br /> 416 2nd Street GALT CA 95632 (209) 744-0112 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> David Winkler 8883059-UC <br /> Mailing Address Phone # <br /> 416 2nd Street GALT CA 95632 (209) 744-0112 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Felix Ramirez 8883072-UC <br /> Mailing Address Phone # <br /> 416 2nd Street GALT CA 95632 (209) 744-0112 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Edward Stearns 8883080-UC <br /> Mailing Address Phone # <br /> 416 2nd Street GALT CA 95632 (209) 744-0112 <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 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 /> Attach additional page(s) containing all the information in section 11 if more alternates are used. <br /> ID = Identification, ICC = Intemational Code Council <br />