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Saw, RECEiVIL12 <br /> — — <br /> ZJAN 0 3 2005 <br /> Owner Statements of Designated Underground Storage Tank ( perator <br /> and Understanding of and Compliance with UST Requi <br /> Facility Name:Safeway Stores,Inc Facility ID#: 1769(135357) <br /> Facility Address:2808 Country Club Blvd Reason for Submitting this Form(Check One) <br /> Stockton,CA 95204 ❑ Change of Designated Operator <br /> Facility Phone#:209461-5555 ❑ Update Certificate Expiration Date <br /> Designated UST Ouerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Ian Moorehead Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferentfrom above):Gilbarco/Needer-Root ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:800/253-8054 ❑ Service Technician x❑ Third-Party <br /> International Code Council Certification#:SEE ATTACHED PASSING TEST Expiration Date: 12/15/06 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name:PLEASE SEE ATTACHED LISTING Relation to UST Facility(Check One) <br /> Business Name(If dii ferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Daze: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii ferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's 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): Safeway Stores.Inc b GilbarcoNeeder-Root—Emily Dai eau <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/31/2004 O R's P 1E#: 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/ust/contacts/cmpa ag sv htmt. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> r <br />