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RECEIVED <br />Owner Statements of Designated Underground Storage Tank ( STf pQrQtdfl05 <br />and Understanding of and Compliance with UST Requi nts <br />Facility Name: Safeway Stores, Inc <br />Facility ID #: 2707 (227860) <br />Facility Address: 6425 N Pacific <br />Stockton, CA 95207 <br />Reason for Submitting this Forth (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209-472-8600 x1219 <br />Designated UST Operator(s) for this Facilitv <br />PRIMARY <br />Designated Operator's Name: Ian Moorehead <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 191 Third -Party <br />Business Name (Ifdii erentfrom above): Gilbarco/Veeder-Root <br />Designated Operator's Phone #: 800/253-8054 <br />International Code Council Certification #: SEE ATTACHED PASSING TEST <br />Expiration Date: 12/15/06 <br />ALTERNATE 12 tional <br />Designated Operator's Name: PLEASE SEE ATTACHED LISTING <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name pfdiferentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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) - (fl. <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): Safeway Stores. Inc by GilbarcoNeeder-Root — Emily Daieneau <br />SIGNATURE OF TANK OWNER: <br />DATE: 12/31/2004 OWNWS PROW: 800/253-8054 <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca.gov/usticontacts/cuoa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />