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*wner Statements of Designated Underground Storage Tank (UST) or <br />I, 3 2010 <br />and Understanding of and Compliance wifli UST Requirements <br />2JU <br />Facility Name: Wilson Way Chevron <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />X Service Technician 0 Third -Party <br />Facility Address: 437 N. Wilson Way, Stoddon, CA <br />Reason for Submitting this Form (Check One <br />0 Change of Designated Operator <br />international code council certification #: 5243897 -UC <br />Facility Phone#: 21&,U-22--2-344-1 <br />X Update Certificate Expiration Date <br />19 ZI 16 11 <br />Designated Operator's Name: Alex Jabbari <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />X Service Technician 0 Third -Party <br />Business Name (Ydifferentfrom above): <br />international code council certification #: 5243897 -UC <br />Expiration Date: 140112/2012 <br />1111-1 M U-1 r —Tr- Trl to 1-177 774ry 0 z r r, 17-M <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0 ServiceTechmcian 0 Thffd-Party <br />Business Name (Ydifferentfrom above): <br />57 n 17M to Mt ' i 11 ': "I <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0 ServiceTechnician 0 Third -Party <br />international Code Council Certification #: <br />I I - feAlt*41 MATIT4 4 is <br />iy�e-traimng,maccoraancewimt-atitomiaMeo- <br />Regulations, title 23, section <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />F - <br />DATE: OWNER'S PHONE#: '2z>!77 '2- — <br />I � I WIN <br />AT: <br />T <br />*F TTIE CHANGE. <br />November 2004 <br />qn" <br />