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San Joaquin County blic Health Services Owner Statement Designated Underground Storage Tank(UST) Operator and understanding of Compliance with UST Requirement Facility Name : Chevron Station# 201383 Facility ID: FA0004547 Facility Address : 1960 W 11TH ST, TRACY, CA, Reason for Submitting this Form (Check One) 95376-3738 ✓0 Change of Designated Operator Facility Phone#: Q 209-8363181 ® Update Certificate Expiration Date Q Initial Submittal Of Designated Operator DESIGNATED UST OPERATORS FOR THIS FACILITY PRIMARY Designated Operator's Name : Edward Dahlgren Relation to UST Facility(Check One) Business Name(If different from above) : Chevron Products Company =lOwner ❑Operator �mployee Designated Operator's Phone#: (925)842-9002 E�ervice Technician ®Third-Party International Code Council Certification#: 8000863-UC Expiration Date 9/28/2012 ALTERNATE1(Optional) Designated Operator's Name : Chevron Designated Operators Relation to UST Facility(Check One) Business Name(If different from above) : Chevron Products Company E:]Dwner [�perator �mployee Designated Operators Phone#: (925)842-9002 E:3ervice Technician ❑Third-Party International Code Council Certification#: Chevron Addendum Expiration Date: 11/24/2011 ALTERNATE2(Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If different from above) : Owner ®Operator ✓'mployee Designated Operator's Phone#: O- Oervice Technician ❑Third-Party International Code Council Certification#: Expiration Date: 11/24/2011 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,title 23,section 2715(c)-(f) Furthermore I understand and am in compliance with the requirements(statutes, regulations, and local ordinances) applicable to underground storaqe 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: 12/3/2010 OWNER'S PHONE#: (925)842-9002