Laserfiche WebLink
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 /> 10182313 Chevron Station#208117 <br /> Facility Address City ZIP Code <br /> 755 S TRACY BLVD TRACY 95376-4753 <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 /> Adel Amarin 8032306 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON, CA 94583 (909) 767-0588 <br /> Name of Designated UST Operator ICC Certification <br /> Adnan Tafla 8372551 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON,CA 94583 (760) 300-5794 <br /> Name of Designated UST Operator ICC Certification <br /> Andrea Vilchis 9704888 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON,CA 94583 (714) 253-2476 <br /> Name of Designated UST Operator ICC Certification <br /> Blanca Gonzalez 8910090 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON, CA 94583 (510) 561-4088 <br /> Name of Designated UST Operator ICC Certification <br /> Christina Lane 8901300 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON, CA 94583 (661) 256-5931 <br /> Name of Designated UST Operator ICC Certification <br /> Darwin Cornelius 8175604 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON, CA 94583 (626) 290-8932 <br /> Name of Designated UST Operator ICC Certification <br /> Debra Rinehart 8372456 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON, CA 94583 (510) 289-1886 <br /> Name of Designated UST Operator ICC Certification <br /> Diane DiPasquale 8261965 <br /> Mailing Address Phone <br /> P.O. BOX 6004,SAN RAMON,CA 94583 (707) 344-2258 <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 3 <br />