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DEC 06 6006 9:5B FSM FR 1761/6 LINCOLN 916 408 0808 TO 17206891011 <br />✓� � uv cuu� 4J' �,� <br />R <br />J <br />Owner Statements of Desipated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />P.II <br />r. e�ib i <br />Facility Name: SAFEWAY NOR CAL 112600 <br />Facili y ID #: 152993 <br />Facility Address: 1804 W. 11T2 STREET <br />Reason for submitting this Form (Check One) <br />TR.ACEY, CA 95376 <br />0 Change of Acsiga&xd Operator <br />Facility Phonc #: 209-830.2950 X1219 <br />Update ICC 4 a=d/or Expiration Date <br />Designated UST Operator(s) for this Facility <br />Designated opa2tor'sNamc: Ian Moorhead Rclatlon to UST Facility (Check One) <br />Business Namc (Ifdifferent from above): GilbarcalVeeder-Root ❑ Owner ❑ Opemor 0 Employee <br />Designatrd Opereto:'s Phone #: 916-947-5285 ❑ Service Technician ® Third -Parry <br />International Code Council Certification $: 5250115 -UC Expirnboc Daze: 10-31-2008 <br />ALTEKNATE 1 (00ond!) <br />Designated Operator's Name: Jim Palmer <br />Relation to UST Facility (Check One) <br />❑ Owner 0 Operator 0 Employee <br />❑ Service Technician 0 'Third -Party <br />Business NF.rne (If dtfferens from abave): Gilbarco Veeder-Root <br />Designated Operator's Phone 4: 831-844-5235 <br />Intematienal Code Council Cerzl$catioa 0: 5254109 -UC <br />Expiration DEC: 02-21-2007 <br />ALTERNATE 2 (Oprtartag <br />Desipared Operator's Name; Daniel Perez Relation to UST Facility (Check One) <br />Business Name (jdfferentfromabave):GilbarcoVeeder-Rcor C Owner ❑ Operator O Employee <br />De�ignsted Operator's Phone 4: 916-718-0139 0 Service Techaicim © Third -Party <br />International Code Council Certification *: 5246161 -UC Expirston Date: 11 -30-2006 <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 inspectzons and annual facility employee traizung, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (fl. <br />Furthermore, X understand and am in compliance with the requirements (statutes, <br />regidations, and local ordinances) applicable to underground storage talnks. <br />IYAba OF TANK OWNER (Please Print): SAYXWAY NOR C - STAN OLEA <br />SIGNATURE OF TANK OWNER: <br />DATE: 11/10%2006 O'WNER'S PHONE #: (925) 467-2707 <br />November 2004 <br />