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San J quin County Public Health S <br /> ' Owner Stateme - f Designated Underground Storage Ta k ST)Operator and <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 /> 952062334 <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: Suelynn M Silva 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#: 5244588-UC Expiration Date: 22-Aug-08 <br /> ALTERNATE2(Opdonal) <br /> Designated Operator's Name: Chevron Designated gators Relation to UST Facility(Check On <br /> Business Name(If different from above): Chevron Products Compan ❑ Owner ❑ Operator W Employee <br /> 11 <br /> Designated Operator's Phone#: (925)842-9002 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Chevron Addendum Expiration Date <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check On <br /> Business Nate(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 and <br /> 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 product Company,Attn:Permit Desk <br /> SIGNATURE OF TANK OWNER 415 <br /> OR OWNER'S AGENT(Please Print): &&/ <br /> DATE: 3/12/2007 OWNER'S PHONE (925)842-9002 <br />