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Appendix XI <br /> Underground Storage Tank <br /> Designated UST Operator Identification Form <br /> TYPE OF ACTION ❑ New UST Installation 0 New/Changed Designated Operator <br /> 1. FACILITY INFORMATION <br /> CERS ID Facility Name <br /> 10180905 PACIFIC SERVICE STATION <br /> Facility Address City ZIP Code <br /> 6131 PACIFIC AVE � STOCKTON 95207 <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 /> David Winkler 8883059-UC <br /> Mailing Address Phone <br /> 416 2nd Street Galt, CA 95632 209-744-0112 <br /> Name of Designated UST Operator ICC Certification <br /> Zane Nimmo 8883064-UC <br /> Mailing Address Phone <br /> 416 2nd Street Galt, CA 95632 209-744-0112 <br /> Name of Designated UST Operator 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 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 ICC Certification <br /> Amy Winkler 9951352- UC <br /> Mailing Address Phone <br /> 416 2nd Street Galt, CA 95632 209-712-0112 <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 /> Page 1 of 1 <br />