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03/0 <br /> .;/2009 10:47 FAX 9258425660 CHEVRON PRODUCTS, COMPANY Q001 <br /> 0 San J oaquionty Public Health Services <br /> Owner Statement of Designated Underground Storage Tank(UST) Operator and : <br /> understanding of Compliance with UST Requirement /_Z_ <br /> F*;c Zoq,-JYIS-3,05 ?,gjs <br /> Facility Name Chevron Stabon# 201$83 Facility ID: FA0004547 <br /> Facility Address: 1960 W 11TH ST, TRACY, CA, Reason for Submitting this Form (Check One) <br /> 953763738 Change of Designated Operator <br /> Update Certificate Expiration Date <br /> Facility Phone#: (209)836-3181 Initial Submittal Of Designated Operator <br /> DESIGNATED LIST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operatoes Name : John Daley Relation to LIST Facility(Check One) <br /> Business Name(if different from above) : Chevron Products Compan) L]Owner L] Operator E]Employee, <br /> Designated Operator's phone#: (925) 842-9002 E]Servi ce7echnician [I Third-Party <br /> International Code Council Certification 9:8000863-UC Expiration Date : 11/29/2009 <br /> ALTERNATEI(Optional) <br /> Designated <br /> ignated Operator's Name : Chevron Designated Operators Relation to UST Facility(Check One) <br /> Business Name(if different from above) : Chevron Products Company 0 Owner ElOperator [DEmployee <br /> Designated Operators Phone#; (926)842-9002 []Service Technician 0 Third-Party <br /> International Code Council Certification#Chevron Addendum Expiration.Date: <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name:—Helen H McCarty Relation to UST Facility(Check One) <br /> Business Name(if different from above) : Chevron Products ❑ Owner 0 Operator 21 Employee <br /> Company <br /> Designated Operator's Phone#: (209)536-3181 ❑service Technician L)Third-Party <br /> International Code Council Certification#L 8001455-UC Expiration Date: 11/16/2009 9:18:OOA <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST 13E 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)'llsted above will serve as the Designated <br /> LIST 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 <br /> OR OWNERS AGENT(Please Print) : <br /> DATE: 3/2/2009 OWNER'S PHONE (925)842-9002 <br />