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7JAN CEIVED 0 3 2005 Owner Statements of Designated Underground Storage Tank (Uperator and Understanding of and Compliance with UST Requir — Facility Name:Safeway Stores,Inc Facility ID#:2600(152993) Facility Address: 1804 W 11th St Reason for Submitting this Form(Check One) Tracy,CA 95376 ❑ Change of Designated Operator Facility Phone#:209-830-2950 ❑ Update Certificate Expiration Date DesiLynated UST Overator(s) for this Facility PRIMARY Designated Operator's Name:Ian Moorehead Relation to UST Facility(Check One) Business Name(Ifdifferent from above):Gilbarco/Veeder-Root ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:800/253-8054 ❑ Service Technician El Third-Party International Code Council Certification#:SEE ATTACHED PASSING TEST Expiration Date: 12/15/06 l.A-M 1 R Am^%T ALTERNATE 1 (Optional Designated Operator's Name:PLEASE SEE ATTACHED LISTING Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(Ifd ierent from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: I certify that, for the facility indicated at the top of this page,the individual(s) 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):—Safeway Stores Inc by Gilbarco/Veeder-Root—Emily Dai eau SIGNATURE OF TANK OWNER: DATE: 12/31/2004 O ER'S P E#: 800/253-8054 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/ust/contacts/Ma agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004