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San Joaquin Couublic Health Services <br /> Owner Statement"0Designated Underground Storage nk(UST) Operator and <br /> understanding of Compliance with UST Requirement wpRnml <br /> Facility Name : Chevron Station# 201761 Facility ID: FA0004521 rr <br /> Facility Address : 1103 S MAIN ST, MANTECA, Reason for Submitting this Form (Chuck 114Q X010 <br /> CA, 95337-5743 ✓❑ Change of Designated O <br /> bNr"rWNTaL H <br /> Facility Phone# : O 209-8250174 ❑ Update Certificate ExpirationPfANIT/SERVICE'S <br /> ❑ 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 ❑ Owner ❑ Operator ❑✓ Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician <br /> ❑ Third-Party <br /> International Code Council Certification#: 8016980-UC Expiration Date : 9/28/2012 <br /> ALTERNATE1(Optional) <br /> Designated Operator's Name . Chevron Designated Operators s Relation to UST Facility(Check One) <br /> Business Name(If different from above) : Chevron Products Compan ❑Owner ❑Operator ✓❑Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician ❑ Third-Party <br /> International Code Council Certification# :Chevron Addendum Expiration Date : 9/28/2012 <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name : Relation to UST Facility(Check One) <br /> Business Name(if different from above) : ❑ Owner ❑ Operator❑✓ Employee <br /> Designated Operator's Phone# : O - ❑Service Technician ❑ Third-Party <br /> International Code Council Certification# : Expiration Date : 11/24/2011 <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION <br /> WITHIN 30 DAYS OF THE CHANGE <br /> 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: 12/13/2010 OWNER'S PHONE#: (925)842-9002 <br />