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San Joaquin County <br /> tY <br /> Environmental Health Department <br /> 600 E.Main Street Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(209) 468-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Kettleman Chevron and SMK Chevron Facility ID#:FA0003803&FA0003835 <br /> Facility Address:601 E.Kettleman Ln.Lodi,CA 95240& Reason for Submitting this Form(Check One) <br /> 25651 N.Hwy 99 Acampo,CA 95220 ❑ Change of Designated Operator <br /> Facility Phone#:209 333-0305 X Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Alex Jabbari Relation to UST Facility(Check One) <br /> Business Name(If different from above):Norcal Petroleum Services ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:925-389-1262 ❑ Service Technician Third-Party <br /> International Code Council Certification#:5243897UC Expiration Date:10-6-14 <br /> ALTERNATE 1(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: <br /> ALTERNATE 2 (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: <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 <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations,title 23, section 2715(c) - (f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print):_ arvinder Singh for SMK Chevron and Promod <br /> Trehan for Kettlean Chevron. 12 Z <br /> SIGNATURE OF TANK OWNER: Jdnyv <br /> DATE: / OWNER'S PHONE#: a <br /> November 2004 <br />