Cal. Code Regs. Tit. 23, div. 3, ch. 16, app XI

Current through Register 2024 Notice Reg. No. 50, December 13, 2024
Appendix XI - Underground Storage Tank Designated UST Operator Identification Form

TYPE OF ACTION [] New UST Installation [] New/Changed Designated Operator

1. FACILITY INFORMATION

CERS IDFacility Name
___________________________
Facility AddressCityZIP Code
___________________________

2. DESIGNATED UST OPERATOR INFORMATION

Print names exactly as shown on the ICC certification.

Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________
Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________
Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________
Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________
Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________
Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________
Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________
Name of Designated UST OperatorICC Certification
___________________________
Mailing AddressPhone
___________________________

Additional copies of this page may be attached.

CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, UST = Underground Storage Tank

Cal. Code Regs. Tit. 23, div. 3, ch. 16, app XI

1. New Appendix XI filed 8-27-2018; operative 10-1-2018 (Register 2018, No. 35).
2. Repealer and new appendix filed 8-27-2020; operative 10-1-2020 (Register 2020, No. 35). Filing deadline specified in Government Code section 11349.3(a) extended 60 days pursuant to Executive Order N-40-20 and an additional 60 days pursuant to Executive Order N-66-20.
1. New Appendix XI filed 8-27-2018; operative 10/1/2018 (Register 2018, No. 35).