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
Facility Name
Facility Address
City
ZIP Code
2. DESIGNATED UST OPERATOR INFORMATION Print names exactly as shown on the ICC certification. Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Name of Designated UST Operator
ICC Certification
Mailing Address
Phone
Additional copies of this page may be attached.
CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, UST = Underground Storage Tank Page 1 of 1