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San Jo"-in County Public Health Services <br /> Owner Statement of Designated Underground Storage Tank(UST)Operator and <br /> understanding of Compliance with UST Requirement <br /> Facility Name <br /> :Chevron Station#98264 Facility ID: FA0003715 <br /> Facility Address75 TRACY BLVD,TRACY,CA,953041502 Reason for Submitting this Form(Check One)® Change of Designated Operator <br /> Facility Phone# 08)836-9422 _ ® Update Certificate Expiration Date <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operator's Name <br /> Ravinder Paul Jutla Relation to UST Facility(Check On <br /> Business Name(If different from above): [I Owner ❑ Operator © Employee <br /> 482-1278 E] Service Technician ❑ Third-Part <br /> Designated Operator s Phone#: (209> <br /> International Code Council Certification#: 5245967-UC Expiration Date: 10-Nov-06 <br /> ALTERNATEI(Optionaq <br /> Designated Operator's Name: Relation to UST Facility(Check On <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check On <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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 Califomia 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 Company/ <br /> DATE: 12128120134 OWNER'S PHONE (925)842-9 <br />