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�P <br /> Owner Statements of Designated Underground Storage Tank (UST) <br /> Operator and Understanding of and Compliance with UST requirements <br /> Facility Name: SAFEWAY SITE#2600 Facility ID#: 152993 <br /> Facility Address: 1804 W 11 TH ST Reason for Submitting this Form(Check One) <br /> TRACY,CA 95376 ❑x Change of Designated Operator <br /> Facility Phone#: 209-830-2950 ❑ Update ICC#and/or Expiration Date <br /> Designated UST Operators) for this Facility <br /> Prima (Optional) <br /> Designated Operator's Name: Ryan Wyatt Relation to UST Facility(Check One) <br /> Business Name(If different from above):Gilbarco Veeder-Root ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 559-999-2301 ❑ Service Technician ❑x Third-Party <br /> International Code Council Certification#: 5315333-UC Expiration Date: 7/23/2009 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name:SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑x Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2(Optional) <br /> Designated Operator's Name: SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑x 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 <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 Veeder-Root—Michael Sutton <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/10/2008 OWNER'S PHONE#: 336-312-2895 <br /> November 2004 <br />