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s <br /> San Joaquin Count lic Health Services <br /> Owner Statementftesignated Underground Storage Ta ST)Operator and <br /> understanding of Compliance with UST Requirement <br /> Facility Name: Chevron Station# 209167 Facility ID: FA0012532 <br /> Facility Address : 1234 YOSEMITE AVENUE, Reason for Submitting this Form (Check One) <br /> MANTECA, CA, 95336-5002 ✓� Change of Designated Operator <br /> Facility Phone#: ()209-8247433 ® Update Certificate Expiration Date <br /> ® Initial Submittal Of Designated Operator <br /> DESIGNATED UST OPERATORS FOR THIS FACILITY <br /> PRIMARY <br /> Designated Operator's Name : Edward Dahlgren Relation to UST Facility(Check One) <br /> Business Name(If different from above) : Chevron Products Company EJowner ®Operator �mpioyee <br /> Designated,Operator's Phone# : (925)842-9002 Oservice Technician ❑Third-Party <br /> International Code Council Certification#: 8000863-UC Expiration Date : 9/28/2012 <br /> ALTERNATE1(Optional) <br /> Designated Operator's Name : Chevron Designated Operators Relation to UST Facility(Check One) <br /> Business Name(If different from above) : Chevron Products Company Downer EDoperator [E�mployee <br /> Designated Operator's Phone#: (925)842-9002 Elervice Technician Third-Party <br /> International Code Council Certification#: Chevron Addendum Expiration Date : <br /> ALTERNATE2(Optional) <br /> Designated Operator's Name : Relation to UST Facility(Check One) <br /> Business Name(If different from above) : Owner ®Operator ✓ mployee <br /> Designated Operator's Phone#: ()- Oservice Technician QThird-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 employee <br /> 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: 12/3/2010 OWNER'S PHONE#: (925)842-9002 <br />