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UNDERGROUND STORAGE TANK <br /> 7underground <br /> TED UNDERGROUND STORAGE TANK OPERATOR IDENTIFICATION FORM (Page 1 of 1 ) <br /> storage tank (UST) facility must have at least one designated UST operator. A copy of this completed form must be <br /> mitted via either the California Environmental Reporting System (CERS) or an equivalent local Unified Program Agency <br /> g 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).] <br /> Type of Action ❑ New UST Installation ❑ Change of Owner or Operator N1 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 /> Please see attached list <br /> Business Site Address City ZIP Code <br /> The individuals) 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 2716(c) and 2716. <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATORS INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Kris Bell 8833000 <br /> Mailing Address Phone # (408) 971 -2445 <br /> 680 Quinn Ave . San Jose , Ca 95112 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification# <br /> Brian McPheeley 8822062 <br /> Mailing Address Phone # (408) 971 -2445 <br /> 660 Quinn Ave . San Jose , Ca 95112 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Maria Guarnelli 8158671 <br /> Mailing Address Phone # <br /> 660 Quinn Ave . San Jose , Ca 95112 (408) 971 -2445 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # <br /> Deborah Ward 8818688 <br /> Mailing Address Phone # <br /> 680 Quinn Ave . San Jose , Ca 95112 (408) 971 -2445 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) ICC Certification # 8868021 <br /> Theodore Van Bobber <br /> Mailing Address Phone # <br /> 680 Quinn Ave. San Jose , Ca 95112 (408) 971 -2445 <br /> Name of Designated UST Operator (Print as shown on the ICC certificatlon.) ICC Certification # <br /> Samantha McMahan 8950093 <br /> Mailing Address Phone # <br /> 680 Quinn Ave . San Jose , Ca 95112 (408) 971 -2445 <br /> Name of Designated UST Operator (Print as shown on the ICC certification.) iCC Certification # <br /> 9023055 <br /> Richard Schmidt <br /> Mailing Address Phone # <br /> 680 Quinn Ave. San Jose, Ca 95112 (408) 971 -2445 <br /> Name of Designated UST Operator (Print as shown on the ICC certifrcallon.) ICC Certification # <br /> 9026811 <br /> Rita Martinez <br /> Mailing Address Phone # <br /> 680 Quinn Ave. San Jose, Ca 95112 (408) 971 -2445 <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 = idenfiflcabon, ICC = International Code Council <br />