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San Joaquin Count blic Health Services <br /> Owner Statement sesignated Underground Storage TWUST) Operator and <br /> understanding of Compliance with UST Requirement <br /> Facility Name : Chevron Station# 99840 Facility ID: FA0003717 <br /> Facility Address : 4344 WATERLOO RD, Reason for Submitting this Form (Check One) <br /> STOCKTON, CA, 95215 ❑ Change of Designated Operator <br /> Facility Phone#: ()209-9312186 F/_1 Update Certificate Expiration Date <br /> ❑ Initial Submittal Of Designated Operator <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operator's Name : John Daley 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# : 8000863-UC Expiration Date : 11/24/2011 <br /> ALTERNATE1(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 ❑Owner ❑Operator Q Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician ❑ Third-Party <br /> International Code Council Certification# :Chevron Addendum Expiration Date : 9/29/2008 <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name : Relation to UST Facility(Check One) <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 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) : Chevron product Company,Attn: Permit Desk <br /> SIGNATURE OF TANK OWNER 40" <br /> OR OWNER'S AGENT(Please Print) : Uf <br /> DATE: 1/29/2010 OWNER'S PHONE#: (925)842-9002 <br />