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San Joaquin County Environmental Health.Department Owner Statement of Designated Underground Storage Tank( STS Operator and understanding of Compliance with UST Requirement Facility Name: Chevron Station## 99840 f=acility ID: FA0003717 Facility Address: 4344 WATERLOO RD, Reason for Submitting this Form(Check 6*' STOCKTON, CA, 36215 ` ® Change of Designated Operator Facility Phomt : ()209-9332186 ✓ Update Certificate Expiration Date El Initial Submittal Of Designated Operator DESIGNATED UST OPERATORS FOR THUS FACILITY PRIMARY Designated Operator's Name: Edward Dahlgren Relation to LIST Facility(Check One) Business Name(if different from above):Chevron Products Company []Owner Doperator ✓ Employee Designated Operator's Phone#: (925)842-9002 Service Technician El Third-Party International Code Council Certification#: 8164364 Expiration Date: 6/28/2034 ALTERNATE1(Optional) Designated Operator's Name: Chevron Designated Operators Relation to UST Facility(Check One) Business Name(if different from above): Chevron Products Compan Owner DOperator ✓ Employee Designated O eratoes Phone#: (925)842-9002 [Service Technician Third-Party International Code Council Certification :Chevron Addendum Expiration Date: 6/28/2014 ALTRATE (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(if different from above): El owner El Operator[D Employee Designated Operator's Phone#: ()- 11 Service Technician Third-Party International Code Council Certification : Expiration Date: 6/28/2014 NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE I certify that, for the facility indicated at the top of this page,the individual(s)listed above will serve as the Designated UST Operator(s).The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, We 23,section 2715(c)-(f) Furthermore I understand and am In compliance with the requirements(statutes, regulations,and local ordinances) applicable to underground storage tanks. NAME OF THE TANK OWNER OR OWNER'S AGENT(Please Print): Chevron product Company,Attn: Permit Desk SIGNATURE OF TANK OWNER OR OWNER'S AGENT(Please Print): DATE: 8R/2012 OWNER'S PHONE : (925)842-3002