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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Unified Grocers, Inc. <br />Facility ID #: <br />Facility Address: 1990 Piccoli Road, Stockton, CA 95215 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209.931.9440 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Michael Young <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 209.931.1990 <br />International Code Council Certification #: <br />Expiration Date: 5/30/2015 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Michael Young <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ 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 above will serve as <br />Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br />and annual facility employee training, in accordance with California Code of Regulations, title 23, section <br />2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and <br />local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Prin P rmety, Director Environmental Health & Safety <br />SIGNATURE OF TANK OWNER:/ <br />DATE: 6.4.2013 OWNER'S PRONE #: 323.729.7379 <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.eov/ust/contacts/curia aeys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />