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m . .SUL-02-2012 11:23 Service Station Systems 408 938 8888 P.02 JUL 02 M Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Safeway Facility ID * 2707 Fadilily Address: 6425 N. Pacific Ave. Stockton, CA 95207- Reason for Submitting this Form ® Change of Designated Operator ® Update Certificate Expiration Date Facility Phone: (209) 472-8600 Designated UST Operators) for this Facility Primary Designated Operator's Name: Ran Casey Relation to UST Facilit}(Check One) ❑ Owner ❑ Operator ❑ Employee ® Service Technician a Third -Party Business Name (If different from above): Service Station Systems Designated Operator's Phone #: (408) 971-2445 International Code Council Certification #: 8057554 -UC Expiration Date: 9/15/12 Alternate 1(Optional) Designated Operator's Name: Maria Guarnelli Relation to UST Facility(Check One) ❑ Owner D Operator ❑ Employee ® Service Technician 3 Third -Party Business Name (if different from above): Service Stations stems Designated Operator's Phone #: 408 971-2446 International Code Council Certification #. 8158671 Expiration Date: 5/11/14 Alternate 2 (Optional) Designated Operators Name: Dave Thomas Relation to UST Facilit7(Check One) ❑ Owner ❑ Operator ❑ Employee 19 Service Technician 3 Third -Party Business Name flfdifferent from above): Service Station Systems Designated Operator's Phone #: 408 971-2445 International Code Council Certification #: 5258566 -UC Expiration Date: 6/18114 Tank Owner I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, 1 understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storag a its. Name of tank owner (Please Print►: Signatureof tank owner: - Date: (a -,2y "/ Z Owner's Phone#: �S0' NOTE: 1) Submit this completed form to the Local Agency (NOT the State Water Resources Control Board) By January 1, 2005. The local agency list is available at: www,waterboards,ca,govlust/contacts/oupa_agys.htmi. 2) Notify the Local Agency of any changes to this information within 30 Days of the change.