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Appendix <br /> Underground Storage Tank <br /> Designated DST Operator Identification Form <br /> TYPE OF ACTION ] New UST Installation E-1 Ne lChanged Designated Operator <br /> 1. FACILITY INFORMATION <br /> CERSO Facility Dame <br /> 10443520 JD Service Station, Inc. <br /> Facility Address , City ZIP Code <br /> 9015 Walnut Grove Rd Thornton , CA 95686 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Print narnes exactly as shown on the !00 certffication. <br /> Name of Designated UST Operator -- ]CC Certification <br /> Eric Meeker_ _ 524511-U Exp. 7-15-24 <br /> Mailing Address Phone <br /> 1588 Kingsport AVE Livermore, CA 94550 9259641617 <br /> Nairne of Designated UST Operator ICC Certification <br /> Flailing Address l Phone <br /> Nam9 of Designated UST 0peratcr IGG Certification <br /> Flailing Address Phone <br /> Name of Designated UST Operator ICC Certification <br /> Mailing Address Ptione <br /> Name of Designated UST Operator ICC certification <br /> MaHing Address Phone <br /> Name of Designated IST Operator IOC Certification <br /> Flailing Address Phone <br /> Name of Designated UST Operator ICC Certification <br /> Mailing Address Rhone <br /> Name of Designated UST Operator ICC Certification <br /> Mai Iing Add r ss Phone <br /> Additional copies of this page maybe attached- <br /> CERS _ California Environmental Reporting System. I'D = Identification, ICC = International Code <br /> Council. UST = Underground Storage Tanis <br /> Pogo 1 of 1 <br />