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Appendix XI <br /> Underground Storage Tank <br /> Designated UST Operator Identification Form <br /> TYPE OF ACTION ❑ New UST Installation ❑ New/Changed Designated Operator <br /> 1. FACILITY INFORMATION <br /> CERS ID Facility Name <br /> C(C <br /> =7pciflty ss City ZIP Code <br /> a �1� <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Print names exactly as shown onthe ICC certification. <br /> Name of Designated UST Operator ICC Certification <br /> James Williams 5252274-UC 3125121 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <br /> ERonmAnton <br /> e of Designated UST Operator ICC Certification <br /> 9052121-UC 10/15/21 <br /> ng AddressPhone <br /> ervice Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <br /> Name of Designated UST Operator ICC Certification <br /> Jeramy Cummins 8019661-UC 9/17122 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <br /> Name of Designated UST Operator ICC Certification <br /> Rhome Desbiens 5244364-UC 12129121 <br /> Mailing Address Phone <br /> BZ Service Station Maintenance, PO Box 933, W Sac, Ca 95691 916-371-2380 <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 =Phone <br /> Mailing Address <br /> HNameofgnated UST Operator ICC Certification <br /> ss 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 />