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9 <br /> 5 o5 <br /> Owner Statements of Designated Underground Storage Tank (U 20�n <br /> and Understanding of and Compliance with UST Requireme�ls /rES TH <br /> Facility Name:Vons,A Safeway Company Facility ID#: 1769(135357) <br /> Facility Address:2808 Country Club Blvd Reason for Submitting this Form(Check One) <br /> Stockton,CA 95204 <br /> ❑ Change of Designated Operator <br /> Facility Phone#:209-461-5555 ® Update ICC#and/or Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Ian Moorehead Relation to UST Facility(Check One) <br /> Business Name(Ifdifjerent from above):Gdbarca/Veeder-Root ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:916/947-5285 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:5250115-UC Expiration Date: 12/15/2006 <br /> ALTERNATE and <br /> Designated Operator's Name:PLEASE SEE ATTACHED LISTING Relation to UST Facility(Check One) <br /> Business Name pfdii ferent from above):Gilbarco/Veeder-Root ❑ 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(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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): Safewav Stoges.ine..by Gilborco/Veeder-Root—Emil Dahmeau <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 02/28/2005 ER°S NE#: 800/253-8054 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/ust/contacts/cupa aevs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />