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San <br />in County Public Health S <br />Owner Statement of Designated Underground Storage Tank(UST) Operator and <br />understanding of Compliance with UST Requirement <br />Facility Name: Chevron Station# 91452 Facility ID: FA0003714 <br />Facility Address 334 EAST MAIN STREET, RIPON, CA, Reason for Submitting this Form (Check One) <br />953662902 <br />❑D Change of Designated Operator <br />Facihty Phone# : (209) 599-2313 Update Certificate Expiration Date <br />DESIGNATED UST OPERATORS FOR THIS FACILITY <br />PRIMARY <br />Designated Operator's Name: Alex Jabbari Relation to UST Facility (Check On <br />Business Name (If different from above) : Norcal Petroleum Services, ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone # : (925) 389-1262 ❑ Service Technician © Third -Part <br />International Code Council Certification # : 5243897 -UC I Expiration Date: 02 -Oct -08 <br />ALTERNATEI(Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check On <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above) : <br />Designated Operator's Phone # : <br />International Code Council Certification # : <br />Expiration Date: <br />ALTERNATE2(Optional) <br />Designated Operator's Name: Relation to UST Facility (Check On <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 <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) - (fl <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) : Chevron product Company, Attn: Permit Desk <br />SIGNATURE OF TANK OWNER <br />OR OWNER'S AGENT (Please Print) <br />DATE: 2/21/2007 OWNER'S PHONE (925)842-9002 <br />