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San Joaquin County*ironmental Health Department <br /> Owner Statement of Designated Underground Storage Tank(UST) Operator and <br /> understanding of Compliance with UST Requirement <br /> Facility Name : Chevron Station# 201383 Facility ID: FA0004547 <br /> Facility Address : 1960 W 11TH ST, TRACY, CA, Reason for Submitting this Form (Check One) <br /> 95376-3738 0 Change of Designated Operator <br /> Facility Phone# : ()209-8363181 Rj Update Certificate Expiration Date <br /> 0 Initial Submittal Of Designated Operator <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operator's Name : Edward Dahlgren Relation to UST Facility(Check One) <br /> Business Name(If different from above) :Chevron Products Company 0 Owner ❑ Operator ❑✓ Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician <br /> ❑ Third-Party <br /> International Code Council Certification#: 8164364 Expiration Date : 6/28/2014 <br /> ALTERNATE1(Optional) <br /> Designated Operator's Name : Chevron Designated Operators Relation to UST Facility(Check One) <br /> Business Name(If different from above) : Chevron Products Compan 0 Owner ❑Operator ❑✓ Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician <br /> [I Third-Party <br /> International Code Council Certification# :Chevron Addendum Expiration Date : 6/28/2014 <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name : Relation to UST Facility(Check One) <br /> Business Name(if different from above) : ❑ Owner ❑ Operator0 Employee <br /> Designated Operator's Phone# : () - ❑Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date : 6/28/2014 <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE 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) listed above will serve as the Designated <br /> UST 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 OWNER'S AGENT(Please Print) : <br /> DATE: 8/7/2012 OWNER'S PHONE#: (925)842-9002 <br />