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Designated Operator's Name: Chevron Designated Operators <br />S.A.6 LLIN CIL <br />Designated Operator's Phone # : (92 5) 842-9002 <br />Relation to UST Facility (Check On <br />Owner Li Operator E Employee <br />Service Technician fl Third-Part <br />Business Name (If different from above) : Chevron Products Corn pan <br />Expiration Date: I o 1 (!), International Code Council Certification #: Chevron admendpnent <br />Sa_Liqi:513.$ <br />DATE: 10/3/2005 OWNER'S PHONE (925)842-9002 <br />Expiration Date : International Code Council Certification #: <br />Designated Operator's Name: <br />Business Name (If different from above) : <br />Designated Operator's Phone #: <br />Relation to UST Facility (Check On <br />Owner 0 Operator E Employee <br />Service Technician El Third-Party <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) : <br />SIGNATURE OF TANK OWNER <br />OR OWNER'S AGENT (Please Print) : <br />Chevron Products Company, Attn: Permit Desk <br />• <br />Chevron Products Company / <br />San 1-aquin County Public Health Services <br />Owner Statement of Designated Underground Storage Tank(UST) Operator and <br />understanding of Compliance with UST Requirement <br />Facility Name: <br />Facility Address <br />Chevron Station# 94275 <br /> <br />Facility ID: FA0003712 <br />Reason for Submitting this Form (Check One) <br />E Change of Designated Operator <br />2 Update Certificate Expiration Date <br />2905 W BENJAMIN HOLT DR, STOCKTON, <br />CA, 952073217 <br />Facility Phone# : (209) 478-5555 <br /> <br />DESIGNATED UST OPERATORS FOR THIS FACILITY <br />PRIMARY <br />ALTERNATE1(Optional) <br />a t+6.J r..445 1)&5 1640t-rel* <br />Designated Operator's Name: 6 PertisarceA Relation to UST Facility (Check On <br />Business Name (If different from above) :6164 fact iitowt.,47c. Owner P1 Operator P1 Employee <br />Designated Operator's Phone #: Aoch ges .....qs3 f <br />Service Technician P1 Third-Party <br />International Code Council Certification #: 5.2...s to(0 1 4 Expiration Date: 0 1 t r'T 1 a (0„ <br />ALTERNATE2(Optional)