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SaninCounty Public Health S <br /> Owner Statement of Designated Underground Storage Tank(USI)Operator and <br /> understanding of Compliance with UST Requirement <br /> F ----------------- <br /> Facility Name Chevron Station#208117 Facility ID. FA0007938 <br /> Facility Address 755 S TRACY BLVD,TRACY,CA,953764753 Reason for Submitting this Form(Check One) <br /> Facility Phone# (209)830-0370 Change of Designated Operator <br /> Update Certificate Expiration Date <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Relation to UST Facility(Check On <br /> Designated Operator's Name: Suelynn M Silva <br /> Business Name(If different from above).. Chevron Products Compan ❑ Owner El Operator R Employee <br /> - ----- ----'E] Service Technician n Third-Part <br /> Designated Operator's Phone#: (925)842-9002 <br /> International Code Council Certification#- 52445WUC Expiration Date: 22-Aug-08 <br /> ALTERNATEI(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 El Operator MV Employee <br /> Designated Operator's Phone#: (925)842-9002 Fj Service Technician EjThlrd-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). El owner El Operator [] Employee <br /> El Service Technician El Third-Party <br /> Designated Operator's Phone#: <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 OWNERS AGENT(Please Print): Chevron product Company,Attn:Permit Desk <br /> SIGNATURE OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print): <br /> DATE: 3/26/2007 OWNER'S PHONE (925)842-9002 <br />