Laserfiche WebLink
l San Joaquin Coun�vironmental Health Department <br />Owner Statement o`I"'Designated Underground Storage Ta�ik(UST) Operator and <br />understanding of Compliance with UST Requirement <br />Facility Name: Chevron Station# 208118 <br />Facility Address: 3355E HAMMER LN, <br />STOCKTON, CA, 95212-2817 <br />Facility Phone# : () 209-4773699 <br />PRIMARY <br />Facility ID: FA0008044 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />✓0 Update Certificate Expiration Date <br />0 Initial Submittal Of Designated Operator <br />DESIGNATED UST OPERATORS FOR THIS FACILITY <br />Designated Operator's Name: Edward Dahlgren <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ✓❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Expiration Date: 6/28/2014 <br />Business Name (If different from above) : Chevron Products Company <br />Designated Operator's Phone # : (925) 842-9002 <br />International Code Council Certification #: 8164364 <br />ALTERNATE1(Optional) <br />Designated Operator's Name: Chevron Designated Operators <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑✓ Employee <br />❑Service Technician ❑ Third -Party <br />Expiration Date: 6/28/2014 <br />Business Name (If different from above) : Chevron Products Compan <br />Designated Operator's Phone # : (925) 842-9002 <br />International Code Council Certification # :Chevron Addendum <br />ALTERNATE2(Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ✓❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Expiration Date: 6/28/2014 <br />Business Name (If different from above) : <br />Designated Operator's Phone # : () - <br />International Code Council Certification #: <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) : <br />SIGNATURE OF TANK OWNER <br />OR OWNER'S AGENT (Please Print) : <br />Chevron product Company, Attn: Permit Desk <br />DATE: 8/7/2012 OWNER'S PHONE #: (925)842-9002 <br />