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Sanjftuin County Public Health S <br /> Owner Statement of Designated Underground Storage Tank(UST)Operator and - <br /> understanding of Compliance with UST Requirement <br /> .a,j �t . <br /> Facility Name• Chevron Station#208118 Facility ID• FA0008044 <br /> Facility Address 3355 E HAMMER LN,STOCKTON,CA, Reason for Submitting this Form(Check One) <br /> 952122817 <br /> ❑ Change of Designated Operator <br /> Facility Phone#: (209)477-3699 ❑ Update Certificate Expiration Date <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operator's Name• Suelynn M Silva Relation to UST Facility(Check On <br /> Business Name(If different from above): Chevron Products Compan ❑ Owner ❑ Operator ❑d Employee <br /> Designated Operator's Phone#: (925)842-9002 ❑ Service Technician ❑ Third-Part <br /> International Code Council Certification#: 5244588-UC Expiration Date: 22-Aug-08 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Chevron Designated Operators Relation to UST Facility(Check On <br /> Business Name(If different from above) : Chevron Products Compan ❑ Owner ❑ Operator R] Employee <br /> Designated Operator's Phone#: (925)842-9002 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Chevron Addendum Expiration Date: <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check On <br /> Business Name(If different from above) : ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION 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 <br /> Designated UST Operator(s).The individual(s)will conduct and document monthly facility inspections and <br /> annual facility employee training,in accordance with California Code of Regulations,title 23,section <br /> 2715(c)-(f) <br /> Furthermore I understand and am in compliance with the requirements(statutes,regulations,and local <br /> ordinances)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: 2/21/2007 OWNER'S PHONE (925)842-9002 <br />