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San Joaquin County Public Health Services <br /> Owner Staterne6f Designated Underground Storage j&(UST) Operator and <br /> understanding of Compliance with UST Requirement <br /> Facility Name : Chevron Station# 208117 Facility ID: FA0007938 <br /> F m : <br /> r Reason for Submitting this Form(Check One) <br /> Facility Address : 755 S TRACY BLVD,TRACY, <br /> F CA, 953764753 Change of Designated Operator <br /> Facility Phone#: (209)830-0370 Update Certificate Expiration Date <br /> El Initial Submittal Of Designated Operator <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operatoes Name- John Daley Relation to UST Facility(Check One) <br /> Business Name (if different from above) : Chevron Products Compan) ❑Owner F] Operator R1 Employee <br /> Designated Operator's Phone#: (925) 642-9002 ❑Service Technician [] Third-Party <br /> International Code Council Certification#:8000863-UG Expiration Date : 11/29/2009 <br /> ALTERNATF-I(Optional) <br /> Designated Operators Name . Chevron Designated Operators Relation to LIST Facility(Check One) <br /> Business Name(if different from above) :Chevron Products Company ElOwner 11 Operator 0 Employee <br /> Designated Operatoes Phone#: (925)842-9002 El Service Technician Third-Party <br /> International Code Council Certification#Chevron Addendum Expiration Date: <br /> ALTER NATE2(Optional) <br /> Designated Operator's Name , Y Relation to UST Facility (Check One) <br /> li Business Name (If different from above) : F1 Owner 0 OperatorEl Employee <br /> Designated Operator's Phone El 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 <br /> WITHIN 30 DAYS OF THE CHANGE <br /> I certify that, for the facility indicated at the too of this page,the individual(s)listed above will serve as the Designated <br /> LIST Operator(s)-The individual(s)will conduct and document monthly facility inspections and annual facility <br /> employee training, in 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) Chevron product Company,Attn: Permit Desk <br /> SIGNATURE OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print) <br /> DATE: 12/212008 OWNER'S PHONE#: (925)842-9002 <br />