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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR IDENTIFICATION FORM (Page 1 of 1) <br /> Every underground storage tank (UST)facility must have at least one designated UST operator. A copy of this completed form must be <br /> electronically submitted via either the California Environmental Reporting System(CERS)or an equivalent local Unified Program Agency <br /> electronic reporting 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 <br /> ❑New UST Installation El Change of Owner or Operator New or Change of Designated UST Operator_ <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> JOES TRAVEL PLAZA 101805041 <br /> Business Site Address City ZIP Code <br /> 15600 S HARLAND LATHROP 195330 <br /> The individual(s)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 2715(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 /> AMY WINKLER 71 995 1352-UC <br /> Mailing Address Phone# <br /> 877 BATEMAN WAY GALT CA 95632 T (209) 712-3206 <br /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICG Certification# <br /> DAVID WINKLERJ 8883059-UC <br /> Mailing Address Phone# <br /> 877 BATEMAN WAY GALT CA 95632 (209) 712-6,'�66 <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 /> Name of Designated UST Operator(Print as shown on the ICC certification.) ICC Certification# <br /> Mailing Address Phone# <br /> i 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 /> 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 /> Name of Designated UST Operator(Print as shown on the 1CC certification.) ICC Certification# <br /> • Mailing Address Phone# <br /> Attach additional page(s)containing all the information in section iI if more alternates are used. <br /> ID=Idenl tlon,ICC=Intematieonal Code Gourd <br />