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San Joaquin Cour ublic Health Services <br />Owner Statement r,. Designated Underground Storage Tank(UST)Operator and <br />understanding of Compliance with UST Requireme ECEIVED <br />Facility Name : Chevron Station# 307709 Facility ID: <br />Facility Address: 10858 TRINITY PARKWAY, <br />STOCKTON, CA, 95219 <br />Facility Phone# : () 209-9522213 <br />PRIMARY <br />DEC 2 0 2010 <br />Reason for Submitting this Form (Check One) <br />✓❑ Change of Designate ENTAL HEALTH <br />/SERVICES <br />❑ Update Certificate Expiration Date <br />0 Initial Submittal Of Designated Operator <br />DESIGNATED UST OPERATORS FOR THIS FACILITY <br />Designated Operator's Name : Edward Dahlgren <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑✓ Employee <br />❑ Service Technician ❑ Third -Party <br />Expiration Date : 9/28/2012 <br />Business Name (If different from above) : Chevron Products Company <br />Designated Operator's Phone # : (925) 842-9002 <br />International Code Council Certification #: 8016980 -UC <br />ALTERNATE1(Optional) <br />Designated Operator's Name : Chevron Designated Operators <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator Z Employee <br />❑Service Technician ❑ Third -Party <br />Expiration Date : 9/28/2012 <br />Business Name (If different from above) : Chevron Products Compan <br />Designated Operator's Phone # : (925) 842-9002 <br />International Code Council Certification # :Chevron Addendum <br />ALTERNATE2(Optional) <br />Designated Operator's Name : <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑✓ Employee <br />❑ Service Technician ❑ Third -Party <br />Expiration Date : 9/28/2012 <br />Business Name (If different from above) : <br />Designated Operator's Phone # : () - <br />International Code Council Certification #: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br />WITHIN 30 DAYS OF THE CHANGE <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as the Designated <br />UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility <br />employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f) <br />Furthermore I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) <br />applicable to underground storage tanks. <br />NAME OF THE TANK OWNER <br />OR OWNER'S AGENT (Please Print) : <br />SIGNATURE OF TANK OWNER <br />OR OWNER'S AGENT (Please Print) : <br />Chevron product Company, Attn: Permit Desk <br />DATE: 12/13/2010 OWNER'S PHONE #: (925)842-9002 <br />