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DEC 05 2606 9 : 59 AM FR 1761 /8 LINCOLN 915 408 0808 TO 172088' 101 P 0J. L7 <br /> UtC-6h—Z66h Oy:Sb <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:SAFE WAY NOR CAL f1769 Facility 0#: 135357 <br /> Facility Address:2808 COUNTRY CLUB BLVD Reason for Submitting this Foran.(Check One) <br /> STOCKTON,CA 95204 <br /> Feed/ Phone#: 20961-5555 0 Change ofDesignatod Operator <br /> Facility Update ICC#and/or Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> Prima tion=! <br /> Designated Operatai sName:Ian Moorhead Relation to UST Facility(Check One) <br /> Business Name(If6jerenrfrom above): Gllbarco/Vcdd#I Root ❑ Owner C Operator p Employee <br /> Designated Operwoi s Pbone#:916-947.5285 0 Service Tecbaicin 0 Third-Parry <br /> lntemational Code Council CcrhYcation#: 5250115-UC Expiration Date:10-31-1008 <br /> ALTERNATE I(Optional) <br /> Dcsigoated Operator's Name:Am Palmer Relation to UST Facility(Check Ona) <br /> Business Namc Vfdrfferentfrom above): Gllbarca YeedervRoor ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Pbnna#:831.840-5235 ❑ Service Technician 0 Tbird-Party <br /> Intermational Code Council Certification#:5254109-UC Expiration Date,.02.21.2007 <br /> ALTERNATE 2(Optional) <br /> Designated Operator's Aymara Daniel Perez Relation to UST Facility(Check One) <br /> Business Namc(1fd(Bererufrom above):Gilbarco Veeder-Root 0 Owmer ❑ Operator ❑ Employee <br /> Designated Operatoi s Phone#:916-718.0139 ❑ Service Teebrticien © Third-Pavy <br /> Intematioael Code Council CertWcation#:5246161-11C Expiration Date: 11-30-2006 <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): SAFEW Y NOR CAI, -STAN OLEA <br /> SIGNATURE OF TANK OWNER: r" g� <br /> DATE: 11/10/2006 OwNER'S PHONE#: (925)467-2707 <br /> November 2004 <br /> TOTAL P.07 <br /> ** TOTAL PAGE . 13 ** <br />