Laserfiche WebLink
San Joaquin County,clic Health Services <br /> Owner Statement o 3esignated Underground Storage Tan-k(UST) Operator and <br /> understanding of Compliance with UST Requirement <br /> Facility Name : Chevron Station# 98264 Facility ID: FA0003715 <br /> Facility Address : 3775 TRACY BLVD, TRACY, Reason for Submitting this Form (Check One) <br /> CA, 95304-1502 ✓❑ Change of Designated Operator <br /> Facility Phone# : Q 209-8369422 ❑ Update Certificate Expiration Date <br /> ❑ Initial Submittal Of Designated Operator <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operator's Name : Andrew Baptista Relation to UST Facility (Check One) <br /> Business Name (If different from above) : ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone# : (209) 947-5675 ❑Service Technician s❑ Third-Party <br /> International Code Council Certification # : 8014658-UC Expiration Date : 7/28/2012 <br /> ALTERNATE1(Optional) <br /> Designated Operator's Name : Relation to UST Facility (Check One) <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 : 7/28/2012 <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name : Relation to UST Facility (Check One) <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 INFORMATION <br /> 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 <br /> UST 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: 4/4/2011 OWNER'S PHONE#: (925)842-9002 <br />