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01/07/2005 15:35 408-782-5185 SAFEWAY 1891 PAGE <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Safeway Stems, Inc Facility ID #! 2707 (227860) <br />Factility Address: 6425N Pacific Reason for Submitting this Forth (Check One) <br />Stockton, CA 95207 ❑ Change of Designated Operator <br />Facility Phone#: 209-472.8600 x1219 ❑ Update Certificate Expiration Date <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: In Moorehead <br />Relation to UST Facility (Check One) <br />❑ Owncr ❑ Operator ❑ Employee <br />❑ Service Technician M Third -Party <br />Business Name(Ifdierentfmm above): Gffbarco/freeder-Root <br />Designated Operator's Phone #: 800/253-8054 <br />International Code Council Certification #: SEE ATTACHED PASSING TEST <br />CONFIRAIARON <br />Expiration Date: 1211.5106 <br />ALTERNATE ttianaT <br />Designated Operator's Name: PLEASE SEE ATTACHED LISTING <br />Relation to UST Facility (Check One) <br />O Owner ❑ Operator ❑ Employs: <br />❑ Service Technician ❑ Third -Party <br />BusinesgName (Jjdi�erwafrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (OpkonaQ <br />Designated Operator's Name: <br />Susincss Naine (ij di�eres Ji <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Relation to UST Facility (Check One) <br />❑ Owner 0 Operator 0 L^mployee <br />h <br />Expiration Date: <br />1 certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Operators). 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(e) - (f). <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 <br />SIGNATURE OF TANK OWNER: <br />DATE: 12/31/2004 OWNER'S PHONE #: 800/253-8054 <br />NOTE: 1) SUBMrr THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGFNCY UICT M Ave] Aut c <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE <br />November 2004 <br />