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kesignated <br /> San Jr yin County Public Heath Services <br /> Owner StatementUnde round Stora a Tankr O rator and <br /> � g l )Operator <br /> understanding of Compliance with UST Requirement <br /> Facility Name• Chevron Station#99840 Facility ID; FA0003717 <br /> Facility Address 4344 WATERLOO RD,STOCKTON,CA, Reason for Submitting this Form(Check One) <br /> 952152334 <br /> ❑Change of Designated Operator <br /> Facility Phone#: (209)931-2186 ❑ Update Certificate Expiration Date <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <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)842-9002 ❑ Service Technician ❑ Third-Part <br /> International Code Council Certification#: Chevron admendment Expiration Date <br /> i <br /> ALTERNATE 1(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# <br /> ❑ Service Technician ❑ Third-Part <br /> Y <br /> International Code Council Certification# : Expiration Date <br /> ALTERNATE2(Optiona l) <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 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 Company/ <br /> DATE: 12/28/2004 OWNER'S PHONE (925)842-9002 <br />