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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: Flying J—Ripon Facility ID#: <br /> Facility Address: 1501 Jake Tone Road Reason for Submitting this Form(Check One) <br /> Ripon CA 9 Change of Designated Operator <br /> Facility Phone#:209-599-4141 0 Update Certificate Expiration Date <br /> Designated.UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Jody Demello-Rice Relation to UST Facility(Check One) <br /> Business Name(1fdifferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:916-402-3239 El Service Technician R Third-Party <br /> International Code Council Certification#:5308678-UC Expiration Date: 4/20/2009 <br /> ALTERNATE 1 L02&nd <br /> I <br /> Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator R Employee <br /> Designated Operator's Phone#:refer to backup document 0 Service Technician 13 Third-Party <br /> International Code Council Certification#:refer to backup document Expiration Date:refer to backup document <br /> ALTERNATE 2 (Opdomd) <br /> Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) <br /> Business Name(V"differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:refer to backup document c3 Service Technician 9 Third-Party <br /> Intemational Code Council Certification#:refer to backup document Expiration Date:refer to backup document <br /> I certify that,for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated <br /> UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility <br /> employee training,in accordance with California Code of Regulations,tide 23,section 2715(c)-(f). <br /> Furthermore,I understand and am In compliance with the requirements(statutes,regulations,and local <br /> ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): YjAne J <br /> SIGNATURE OF TANK OWNER: <br /> Jeff 19rren on behalf of Flying J Inc <br /> Date: H-0,44 Owner's Phone#: Main:801-624-1434 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2009.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:hft://www.waterboards.ca.zov/usVcontacts/ <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> April 2008 <br />