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SanCounty Public Health Service <br /> Owner Statement of Designated Underground Storage Tank(UST) Operator and <br /> understanding of Compliance with UST Requirement <br /> =: (9209) <br /> evron Station#210997 <br /> Facility ID: <br /> LONY DRIVE @ HWY 99,RIPON,CA, <br /> 66 Reason for Submitting this Form (Check One) <br /> Change of Designated Operator <br /> 9)599-0149 <br /> Update Certificate Expiration Date <br /> PRIMARY DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> Designated Operator's Name: Chevron Designated Operators Relation to UST Facility(Check On <br /> Business Name(If different from above): Chevron Products Compan © Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (925)642-9002 ❑ Service Technician ❑ Third-Part <br /> International Code Council Certification#: Chevron admendment Expiration Date <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check On <br /> Business Name(If different from above) ; ❑ Owner <br /> ❑ Operator El Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certifcafon# <br /> Expiration Date: <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name <br /> Relation to UST Facility(Check On <br /> Business Name(If different from above): ❑ Owner <br /> Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification# <br /> Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION 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 <br /> Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations,title 23,section <br /> 2715(c)-(f) <br /> Furthermore I understand and am in compliance with the requirements(statutes,regulations,and local <br /> ordinances)applicable to underground storage tanks. <br /> NAME OF THE TANK OWNER <br /> OR OWNER'S AGENT(Please Print): Chevron Products Company,Attn:Permit Desk <br /> SIGNATURE OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print): Chevron Products Comp. <br /> DATE: 1 /2aMooa OWNERS PHONE (925)842- <br />