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San Joaquin Coun0vironmental Health Department <br /> Owner Statement i,, Designated Underground Storage T.,iK(UST) Operator and <br /> understanding of Compliance with UST Requirement <br /> Facility Name : Chevron Station# 210997 Facility ID: FA0013918 <br /> Facility Address : 1442 A COLONY DRIVE, Reason for Submitting this Form (Check One) <br /> RIPON, CA, 95366-9421 Change of Designated Operator <br /> Facility Phone#: ()209-5990149 ❑ Update Certificate Expiration Date <br /> EJ Initial Submittal Of Designated Operator <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operator's Name : Edward Dahlgren Relation to UST Facility (Check One) <br /> Business Name(If different from above) :Chevron Products Company ❑ Owner ❑ Operator ❑✓ Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician ❑ Third-Party <br /> International Code Council Certification # : 8164364 Expiration Date : 6/28/2014 <br /> ALTERNATEI(Optional) <br /> Designated Operator's Name : Chevron Designated Operators Relation to UST Facility (Check One) <br /> Business Name (If different from above) : Chevron Products Compan ID Owner ❑Operator s❑Employee <br /> Designated Operator's Phone# : (925) 842-9002 El service Technician ❑ Third-Party <br /> International Code Council Certification# :Chevron Addendum Expiration Date : 6/28/2014 <br /> ALTERNATE 2(Optional) <br /> rDesign:ate:dO�perator's Name : Relation to UST Facility (Check One) <br /> ss Name(If different from above) Owner Operator ✓❑ Employee <br /> ated Operator's Phone# : () <br /> ❑Service Technician ❑Third-Party <br /> Expiration Date : 6/28/2014 <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 Chevron product Company, Attn: Permit Desk <br /> OR OWNER'S AGENT (Please Print) : <br /> SIGNATURE OF TANK OWNER <br /> OR OWNER'S AGENT (Please Print) : <br /> OWNER'SPHONE#: (925)842-9002 <br /> Op�E, �Ill'l01't <br /> Page <br />