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San Join County Public Health Services <br />Owner Statement okesignated Underground Storage Tank(UST) Operator and <br />understanding of Compliance with UST Requirement <br />Facility Name • Chevron Station# 201383 Facility IUD: FA0004547 <br />Facility Address 1960 W 11TH ST, TRACY, CA, 953763738 Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />Facility Phone# : (209) 836-3181 ❑ Update Certificate Expiration Date <br />DESIGNATED UST OPERATORS FOR THIS FACILITY <br />PRIMARY <br />Designated Operator's Name • Chevron Designated Operators <br />Relation to UST Facility (Check On <br />d❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Part <br />Business Name (If different from above) : Chevron Products Compan <br />Designated Operator's Phone # : (925) 842-9002 <br />International Code Council Certification # : Chevron admendment <br />Expiration Date : <br />ALTERNATE 1(Optiona t) <br />Designated Operator's Name: <br />Relation to UST Facility (Check On <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above) : <br />Designated Operator's Phone # • <br />International Code Council Certification # : <br />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 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) : <br />SIGNATURE OF TANK OWNER <br />OR OWNER'S AGENT (Please Print) : <br />DATE: 12/28/2004 <br />Chevron Products Company, Attn: Permit Desk <br />Chevron Products Company / <br />OWNER'S PHONE (925)842-9002 <br />