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Owner Statements of Designated Underground Storage Tank (UST) <br />Operator and Understanding of and Compliance with UST requirements <br />Facility Name: SAFEWAY SITE# 2600 <br />Facility ID #: 152993 <br />Facility Address: 1804 W 11TH ST <br />TRACY, CA 95376 <br />Reason for Submitting this Form (Check One) <br />O Change of Designated Operator <br />❑ Update ICC # and/or Expiration Date <br />Facility Phone #: 209-830-2950 x1219 <br />Designated UST Operator(s) for this Facility <br />Primary (Optional) <br />Designated Operator's Name: Kevin Watermolen <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑x Third -Party <br />Business Name (If different from above): Gilbarco Veeder-Root <br />Designated Operator's Phone #: 916-838-6749 <br />International Code Council Certification #: 5250470 -UC <br />Expiration Date: 10/5/2008 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: SEE ATTACHED LIST <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician (] Third -Party <br />Business Name (If dierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: SEE ATTACHED LIST <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑x Third -Party <br />Business Name (If different from 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 <br />above will serve as Designated UST Operator(s). The individual(s) will conduct and <br />document monthly facility inspections and annual facility employee training, in <br />accordance with California Code of 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 c/o Gilbarco Vee r- t — . ael Sutton <br />SIGNATURE OF TANK OWNER: <br />DATE: 5/19/2008 OWNER'S PHONE #: 336-315-2895 <br />November 2004 <br />