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Appendix XI <br /> Underground Storage Tank <br /> Designated UST Operator Identification Form <br /> TYPE OF ACTION ❑ New UST Installation ❑x New/Changed Designated Operator <br /> 1. FACILITY INFORMATION <br /> CERS ID Facility Name <br /> 10182103 UNITED PACIFIC #5446 <br /> Facility Address City ZIP Code <br /> 1403 COUNTRY CLUB BLVD � STOCKTON 95204 <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 /> Evangelina Barroso-Traylor 8200889 <br /> Mailing Address Phone <br /> 3960 Gruenhagen Flat Paso Robles, Ca 93446 (909) 455-2275 <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 /> UN-062 www.unidocs.org Rev.10/01/20 Page 1 of 1 <br />