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0 San Joaquin County Envirlental 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# 96171 Facility ID: FA0003834 <br /> Facility Address : 6633 PACIFIC AVE, STOCKTON, CA, Reason for Submitting this Form(Check One) <br /> 95207-3719 <br /> Facility Phone# : (209)477-4294 Q Change of Designated Operator <br /> lJ Update Certificate Expiration Date <br /> Initial Submittal Of Designated Operator <br /> DESIGNATED UST OPEE&TQRS FOR,THjfi 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 Q Operator ® Employee <br /> Designated Operator's Phone # : (925)842-9002 Service Technician ❑ Third -Party <br /> International Code Council Certification # 8164364 Expiration Date 6/28/2014 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name : Chevron Designated Operators Relation to UST Facility (Check One) <br /> Business Name (If different from above) : Chevron Products Company Owner Q Operator Q Employee <br /> Designated Operator's Phone # : (925)842-9002 Service Technician []Third -Party <br /> International Code Council Certification # Chevron Addendum Expiration Date 1/2/2016 <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name : Relation to UST Facility(Check One) <br /> Business Name (If different from above) : Owner []Operator Q 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 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 Designated UST <br /> Operator(s).The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in <br /> 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) <br /> Chevron producttQMggnv. Aan: Pgrmit Desk <br /> SIGNATURE OF TANK OWNER <br /> OR OWNER'S AGENT (Please Print) <br /> OWNER'S PHONE #: (925)842-9002 <br /> Date :01/29/14 <br />