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UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authoritv Cited• Title 23, Div 3. Ch. 16 Cnlifornio Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Love's Travel Stops #223 (209) 599-0740 FACILITY SITE ADDRESS CITY 1553 Colony Rd. Ripon REASON FOR SUBMITTING THIS FORM(Check One): LJ Change of Designated Operator X Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Kimberly Mills RELATION TO UST FACILITY(Check One) BUSINESS NAME(If differentfrom above): Love's Travel Stops ❑ Owner ❑ Operator ❑X Employee DESIGNATED OPERATOR PHONE: (405) 687-1060 ext. ❑❑❑❑❑ ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8061046-UC EXPIRATION DATE: 3/5/2012 ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: C. Kevin Nickell RELATION TO UST FACILITY(Check One) BUSINESS NAME(If driferentfromabove): Loves Country Stores ❑ Owner ❑ Operator 0 Employee DESIGNATED OPERATOR PHONE: (405) 380-5796 ext. U U❑❑0 ❑ Service Technician U Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8014175 - UC EXPIRATION DATE: 7/31/2010 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: ❑❑❑❑❑ RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdifferentfrom above): ❑❑❑❑❑ ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) —— El Service Technician El Third-Party ext. DUV-1❑ INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: ❑❑❑❑❑ EXPIRATION DATE: ❑❑1111❑ ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: ❑❑❑❑❑ RELATION TO UST FACILITY(Check One) BUSINESS NAME(lfdifferentfrom above): ❑❑❑❑❑ ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: ( ) ext. ❑❑110❑ ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: ❑❑❑❑❑ I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST p,ova:.ar(S). Thi will candu,:t Saud doc;.ii.c.ii woi.ih.� faC:Iity i.tspections and annual faC.iity eh.ploycc trailing in accordance with California Code of Regulations, Title 23, Section 2715(c) through (f). Furthermore, I understand and am in compliance with the requirements(statutes, regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Kimberly Mills for Love's Country Stores of California TANK OWNER TITLE: Environmental Compliance Analyst OWNER PHONE: 405 687-1060 TANK OWNER SIGNATURE: (QADATE: April 12, 2010 INSTRUCTIONS 1. Report the name(s) of the Designated UST Operator(s) as registered with the International Code Council (ICC). ICC certification information is available on-line at: www.iccsafe.org/e/certsearch.htmi. Search for "California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.html. Contact information for other local agencies within California is available at: www.swreb.ca.gov/cwphome/ust/contacts/docs/local_agency_list.xis. LN-062-1/2 www.unidoes.org 09/22/05