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SAN JOAQUIN COUNTY ESRONMENTAL HEALTH DEPARTME IS 304 E. WEBER AVENUE, THIRD FLOOR, STOCKTON, CA 95202 TELEPHONE: (209) 40B-3420 FAx: (209-468-3433 ATTN: RAY VON FLUE Owner Statements of Designated Underground Storage Tank(UST) Operator And Understanding of and Compliance with UST RequiremO Facility Name: Flying J Travel Plaza Facility ID#:FA006672 Facility Address: 1501 North Jack Tone Road Reason for Submitting this Form(ch e) 1 Ripon,CA 95366-9500 11Change of Designated Operator .; t S Facility Phone#: (209)599-4141 Update Certificate Expiration Da ,4'� t Designated UST Oaerator(s)for this Facility PRIMARY Designated Operator's Name: Dan L.Crawford Relation to UST Facility(Check One) ❑Owner ❑Operator 4 Employee Business Name (If different from above): ❑ Service Technician ❑Third-Party Designated Operator's Phone#: 801-296-7717 International Code Council Certification: Expiration Date: 9/30/06 XX4141011640 ALTERNATE 1 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) ❑Owner ❑Operator ❑Employee Business Name (If different from above): ❑ Service Technician ❑Third-Party Designated Operator's Phone#: International Code Council Certification: Expiration Date: ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) ❑Owner ❑Operator ❑Employee Business Name (If dierent from above): ❑ Service Technician ❑Third-Party Designated Operator's Phone#: International Code Council Certification: Expiration Date: NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION WITHINI 30 DAYS OF THE CHANGE. 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,I understand and am in compliance with the requirements(statues,regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER OR OWNER'S AGENT(Please Print): Cliff Yeckes for Flying J Inc. SIGNATURE OF TANK OWNER OR OWNER'S AGENT: DATE: 12-15-04 OWNER'S PHONE#: 801-296-7700 NOTE: 1)SUBMIT THE 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.gov/ust/contacts/cui)a aevs.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.