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01/07/2005 15: 35 408-78?--5185 SAFEWAY 1891 PAGE 63/64 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility NwTie. Safclway btoras, 1;,, i vacuity ID#: 2600(152993) Facility Address: 1804 W 11th St Reason fbr Submitting this Form(Check One) Tracy,CA 95376 Ci Chanae of Desi¢natcd Onomtor Facility Phone k:209-830-2950 a ❑ Updatc Certificate Expiration Date Designated UST Onerator(s) for this Facility PRIMARY Designated Operator's Name'lata Moorehead Relation to UST Facility(Check One) Business Name(If dierent from above): Gilbarco/Veeder-Rood ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: 800/253-8054 ❑ Service Technician 0 Third-Party international Code Council Certification#: SEE ATTACHED PASSING TEST Expiration Date: 12/15/06 ALTERNATE 1 tional Designated Operator's Name:PLEASE SEE ATTACHED LISTING Relation to UST(Facility(Check One) Business Namc(If dffferent from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: d Service Technician 0 Tbird-Party Tnt.cmational Code Council Certification#- Expiration Date: ALTERNATE 2 (Optmnal) Designated Operator's Name; Relation to UST Facility(Check Otae) M ❑ Owner ❑ Operator a i=mpioyec Designated Operator's Phone#: ED 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) - (fl, Furthermore,I understand and am in compliance with the requirements (statutes, regulations, and Iocal ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): Safeway StoresInc - tan Olea SIGNATURE OF TANK OWNER: DATE: 12/31/2004 OWNER'S PHONE#: 800/253-8054 NOLL: 11) lr.lL bQKiVi i'O THE LU(:ku li.l.EPiCY (NC)i'1(4E STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: wvwv_waterboards.ca.e y/ust/contacts/cupa aarys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS Or, THE CHANGE. November 2004