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Appendix XI Underground Storage Tank Designated UST Operator Identification Form TYPE OF ACTION New UST Installation ® New/Changed Designated Operator 1. FACILITY INFORMATION CERS ID 10181391 Facility Name St Josephs Hospital Facility Address 1909 Cemetery city Stockton ZIP Code95204 2. DESIGNATED UST OPERATOR INFORMATION Print names exactly as shown on the ICC certification. Name of Designated UST Operator ICC Certification Nik Zagorov 5264361 Mailing Address Phone PO Box 1394 Lafayette CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Zane Nimmo 8883064-UC Mailing Address Phone PO Box 1394 Lafayette CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Felix Ramirez 8883072-UC Mailing Address Phone PO Box 1394 Lafayette CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Edward Stearns 8883080-UC Mailing Address Phone PO Box 1394 Lafayette CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Erik Hinojosa 9209377 Mailing Address Phone PO Box 1394, Lafayette, CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Yolanda Thruston 8163784 Mailing Address Phone PO Box 1394, Lafayette, CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Marco Alejos 8415074 Mailing Address Phone PO Box 1394, Lafayette, CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Ian Hall 5311539 Mailing Address Phone PO Box 1394, Lafayette, CA 94549 888-500-2435 Name of Designated UST Operator ICC Certification Rafael Armas CER 10577162 CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, UST = Underground Storage Tank Page 1 of 1