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SEL-01-2011 12:42 Service Station Systems 4 38 8888 P.03 Owner Statements of Designated Underground Storage Tank (Ute) Operair 1f), and Understanding of and Compliance with UST Requirq,t '�� Cotj ,; Facility Name' Safeway Facility ID#: 2600 Facility Address; 1804 West 11 Th. Street Reason for Submitting this Form Tracy, CA 95376- a Change of Designated Operator Facility Phone: (209) 830-2950 a Update Certificate Expiration Date Designated UST Operator(s)for this Facility Primary Designated Operator's Name' Bryan L.undien Relation to UST Facility(Check One) Business Name(If different from above). Service Station Systems Q Owner ❑ Operator ❑ Employee 1]esignated Operator's Phone#: 408) 971-2445 a Service Technician a Third-Party International Code Council Certification#: 8001468-UC Expiration Date: 8/16/13 Alternate 1 (Optional) Designated Operator's Name: Ran Casey Relation to UST Facilit�(Check One) Business Name(If different from above): Service Station Systems ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (408) 971-2445 a Service Technician Q Third-Party International Code Council Certification#' 8057554-UC Expiration Date: 9/15/12 Alternate 2(Optional) Designated Operator's Name: Dave Thomas Relation to UST FacilitKCheck One) Business Name(if different from above); Service Station Systems ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: 408 971-2445 ® Service Technician ra Third-Party International Code Council Certification#: 5258566-UC Expiration Date: 7/2/12 Tank Owner I certify that, for the facility indicated at the top of this page, the individuals) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances)applicable to underground storage tanks. Name of tank owner(Please Print): Signature of tank owner: 6'� .- a Date; 6/�1�l� Owner's Phone M NOTE: 1) Submit this completed form to the Local Agency (NOT the State Water Resources Control Board) By January 1, 2005. The local agency list is available at: www.waterboards.ca.gov/usUcontacts/cupa_agys.html. 2) Notify the Local Agency of any changes to this information within 30 Days of the change.