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San Joaquin County Envi ra <br />ntal 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# 208118 Facility ID: FA0008044 <br />Facility Address • 3355 E HAMMER LN, STOCKTON, CA, Reason for Submitting this Form (Check One) <br />95212-2817 <br />Facility Phone# : () (209)477-3699 Q Change of Designated Operator <br />Update Certificate Expiration Date <br />Initial Submittal Of Designated Operator <br />DESIGNATED UST OPERATORS FOR THIS FACILITY <br />PRIMARY <br />Designated Operator's Name : <br />Derek Balonek <br />Relation to UST Facility (Check <br />Owner F1 Operator <br />Service Technician <br />Expiration Date <br />One) <br />Q Employee <br />E] Third -Party <br />6/7/2018 <br />Business Name (If different from above) : Chevron Products Company <br />Designated Operator's Phone # : (925)842-9002 <br />International Code Council Certification # 8455771 <br />ALTERNATE I(Optional) <br />Designated Operator's Name : Chevron Designated Operators <br />Business Name (If different from above) : Chevron Products Company <br />Designated Operator's Phone # : (925)842-9002 <br />International Code Council Certification # Chevron Addendum <br />ALTERNATE2(Optional) <br />Relation to UST Facility (Check One) <br />Owner Q Operator Q Employee <br />Service Technician ®Third -Party <br />Expiration Date : <br />4/25/2017 <br />Designated Operator's Name : !,�Pk, 10 aa1 r <br />Relation to UST Facility (Check One) <br />owner Q operator ❑ Employee <br />Business Name (If different from above) : <br />ervice Technician Third -Party <br />Designated Operator's Phone # E NVI. N UPz 1 <br />Expiration Date 4/25/2017 <br />r � <br />International Code Council Certification # <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 />SIGNATURE OF TANK OWNER <br />OR OWNER'S AGENT (Please Print) <br />Charles Bittle <br />Chevron oroduct Company. Attn: Permit Desk <br />OWNER'S PHONE #: (925)842-9002 <br />Date :02/07/17 <br />