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ti San Joaquin Couublic Health Services <br /> Owner Statementwesignated Underground Storage Tank(UST) Operator and <br /> understanding of Compliance with UST Requiremen <br /> REnmil 12'.— <br /> Facility Name : Chevron Station# 94275 Facility ID: FA0003712 VIZU <br /> EE cc��p <br /> Facility Address : 2905 W BENJAMIN HOLT DR, Reason for Submitting this Form ((Chec$Ar?A10 <br /> STOCKTON, CA, 95207-3217 ✓❑ Change of DesignateE <br /> p�WEM'AL HE,. <br /> Facility Phone# : () 209-4785555 ❑ Update Certificate Expirat " VICEg <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 ❑ Owner ❑ Operator ❑✓ Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician <br /> ❑ Third-Party <br /> International Code Council Certification # : 8016980-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 Compan ❑Owner ❑Operator ❑✓ Employee <br /> Designated Operator's Phone# : (925) 842-9002 ❑Service Technician ❑ Third-Party <br /> International Code Council Certification# :Chevron Addendum Expiration Date : 9/28/2012 <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 : 9/28/2012 <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) : 6�ff� <br /> DATE: 12/13/2010 OWNER'S PHONE#: (925)842-9002 <br />