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UNDERGROUND STORAGE TANK <br /> (� DESIGNATED UNDERGROUND STGRAGI=TANK OPERATOR.IDE..TIFICATION F..ORM (Page 1 of 1) . <br /> this <br /> ed form must be <br /> Eve underground storage tank(UST)facility must have at least one designated UST Reporting System (CERS) or an equivalent r. A copy flocal Unified ltP Program Agency <br /> Every <br /> electronically submitted via either the California Environmental <br /> electronic reporting portal within 30 days of:1)an installation of a UST;2)a change in owner or operator h the UST; or 3)an additionode 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).] New or Change of Designated UST Operator <br /> Type of Action [�New UST Installation ❑Change of Owner or Operator [I <br /> I, FACILITY INFORMATION CERs ID <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> AS,z9 /'6725�Ld66U °? 12` City ZIP Code <br /> Business site Address p� y� � C <br /> d6,5 C � � 3uL" <br /> The individual(s)listed belo wi llconduct <br /> Regulations,tanddocument Title the facility <br /> inspections <br /> ns p coons an sections )ity land 2716oyee ning for the facility listed above in <br /> accordance with California C <br /> DESIGNATED UNDERGROUND STORAGETANK OPERATOR(S)ICC IoN#ORMAT.10 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) <br /> DEW 13/'?erlT r, Phone# <br /> Mailing Address y� <br /> �� /Li. Na 9714 -DC's' 1l ICC Certification# <br /> Name of Designated U5T Operator(Print as shown on the ICC certification.) <br /> Phone# <br /> Mailing Address <br /> ICC Certification# <br /> Name of Designated UST Operator(Print:as shown on the ICC certification.) <br /> l Phone# <br /> CMailing Address <br /> ICC Certification# <br /> Name of Designated UST Operator(PrCC int as shown on the Icertification.) <br /> Phone# <br /> Mailing Address <br /> ICC Certification# <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) <br /> Phone# <br /> Mailing Address <br /> ation.) ICC Certification# <br /> Name of Designated UST Operator(Print as shown on the ICC certific <br /> Phone# <br /> Mailing Address <br /> ICC Cification# <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) <br /> ert <br /> Phone# <br /> Mailing Address <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) <br /> ICC Certification# <br /> Phone it <br /> Mailing Address <br /> CC certific <br /> Name of Designated UST Operator(Print as shown on the Iation.) ICC Certification# <br /> Phone# <br /> Mailing Address <br /> ^� ICC Certification# <br /> Name of Designated UST Operator(Print as shown 0111 he ICC certification.) <br /> Phone# <br /> Mailing Address <br /> Attach additional page(s)containing all the information in section 11 if more alternates are used. <br /> I <br /> ID=Identification,ICC=International Code Council <br /> I <br />