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Owner Statetueuts of Designated Underground Storage Tank(UST) <br /> Operator and Understanding of and Compliance with UST requirements <br /> Factory Nem, SAFEWAY GVR#MUG Pac:Ti4YID*2707 <br /> Facility Address: 6d25 N PACIFIC Rauon fbr gnbraitling this FPrm(Vh=k One) <br /> BTOCKTON,CA 95207 - 0 Change of Desigoaied Opaatra <br /> FacilityPhone#'. 209-072.6600x1219 ❑ Updatc ICC#and/or ExphadmData <br /> Desi¢natcd UST Onerator(s)for this Facility <br /> Pima tloaa <br /> Designated Operator's Name Umcdith Potomn Relation to UST Facility(Cheek One) <br /> Rusinam Natne(IfdlfferenefromaboKk GfPxvao YeedervRoor ❑ Ow.ra. ,) <br /> Opaaror ❑ Employee <br /> Designated Operahx's Phpnc# 916-947-5285 ❑SwAocTerbnidan ® Tbird-Petry <br /> Iutemadonal Code Camel Cerd6catia:M TBD Expiration Dat, 31?=9 <br /> ALTERNATE t(O dPnol) <br /> Designated Operator's Name:SEH ATTACHED LIST RalaHoa to UST Facility(Check Ow) . <br /> Business Nam(Ifdl amtfvm above): ❑ Oamc ❑ Opantnr ❑ Empbyx <br /> Designated Operators Phone: ❑ Stn*a Te4ndd= res! T5ixUParty <br /> Inwrantional Code Coundl Catiscation#: paox <br /> ALTERNATE 2 fVpteoaat <br /> beaignatad Opmata'a Nam, SEE A—I TACREDUST Relation to UST Facility(Check One) <br /> Business Name(7fdtViff from atx> ❑ Owner ❑ operator ❑ Employee <br /> Deaignsta3 Opm wr's Phono#: ❑ Savior Technician fat -aW.P,* <br /> Intonational Code Council Certification#: Expiraden Data: <br /> I sonify that,for the facility indicated at the top of this pane,the individual(s)listed <br /> above will serve as Designated UST Operator(s). The individual(s)will conduct and <br /> doenmetlt monthly facility inspections and annual facility employee tabft,in <br /> accordance with California Code of Regulations, title 23,section 2715(c)-(f). <br /> FurMerwore,I understand and am in compifanee with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Pleue Print): SAFEWAY—Stan Oka <br /> SIGNATURE OF TANK OWNER: 44 <br /> DATE: 4/9/2007 OWNER'S PHONE#: 925-467-2707 <br /> NPve:mber 2004 <br />