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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 II Facility Name <br /> Facility Address j City ZIP Cod <br /> I L-6�kfbl <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Print names exactly as shown on the ICC certification. <br /> i Name of Designated UST Operator ICC Certification <br /> e' <br /> Mailing Address j Phone <br /> j c b L <br /> Name of Designated UST Operator ICC Certification <br /> h <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 /> 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 /> 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 /> UN-062 www.unidocs.org Rev.10/01120 Page 1 of 1 <br />