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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Flying J—Ripon Facility ID#: Facility Address: 1501 Jake Tone Road Reason for Submitting this Form(Check One) Ripon CA C Change of Designated Operator Facility Phone#:209-599-4141 Update Certificate Expiration Date Designated UST Operator(s)for this Facility PRIMARY Designated Operator's Name:Jody Demello-Rice Relation to UST Facility(Check One) Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:916-402-3239 ❑ Service Technician R Third-Party International Code Council Certification#:5308678-UC Expiration Date: 4/20/2009 ALTERNATE 1 O tional Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator R Employee Designated Operator's Phone#:refer to backup document ❑ Service Technician ❑ Third-Party International Code Council Certification#:refer to backup document Expiration Date:refer to backup document ALTERNATE 2 (Optional) Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:refer to backup document ❑ Service Technician ®Third-Party International Code Council Certification#:refer to backup document Expiration Date:refer to backup document 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(statutes,regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): Flying J SIGNATURE OF TANK OWNER: Jeff rs on behalf of Flying J Inc Date: 10/28/08 Owner's Phone#: Main: 801-624-1434 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2009.THE LOCAL AGENCY LIST IS AVAILABLE AT: http://www.waterboards.ca.gov/ust/contacts/ 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. October 2008