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01/07/2005 15:35 408-78?-g185 1 SAFEWAY 1891 PAGE 02/04 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> . ;•::,} [C" 1;54(i353;7) <br /> Facility Addrewa:2808 Country Club Blvd Reason for Submitting this Fonn(Check One) <br /> Stockton,CA 95204 ❑ Change of Designated Operator <br /> Facility Phone#:209-461-5555 ❑ Update Certificate Expimtion Dare <br /> Designated UST Operater(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Ian Moorebead Relation to UST Facility(Check One) <br /> Business Name(ffdifferentfrom above):Gflbamo/VeaAr-Root ❑ Owner p Opaator ❑ Employee <br /> Designated Operator's Phone#: 800/253-8054 ❑ Service Technician M Third-Party <br /> international Code Council Certification.#:3EE ATTACHED PASSING TEST Expiration Date: 12/15/06 <br /> ALTERNATE <br /> Designated Operator's Name:PLEASE SEE ATTACHED LISTING Relation to UST Facility(Check One) <br /> Business Name(/fdierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ ScviceTechnician ❑ Third-Party <br /> International Code Council Certification#: Fxn:rntin*r7=�. <br /> ALTERNATE 2 -.. _... ._- �— <br /> (Optroaaf) <br /> Designated operator's Names Relation to UST Facility(Check One) <br /> Business Name(Ifd(ffereret from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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) - (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 Print): gAfeway Stores Inc -Stan Olea <br /> SIGNATURE OF TANK OWNER: e <br /> DATE; 12/31/2004 OWNER'S PHONE#: 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: w.vw.wa[erboards.ca.eov�ircu�on[ac�srouoa agvs.btml. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />