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AAA) RIECIEVED D DEC 0 8 2008 ENVIONMENT HEALTH PERMIT/SERVICES Owner Statements of Designated Underground Storage Tank(UST) Operator and Understanding of and Compliance with LIST Requirements Facility Name: FLYING J TRAVEL PLAZA. Facility ID#: 8098 Facility Address-, 1501 NORTH JACK TONE ROAD Reason for Submitting this Form(Check One) RIPON,CA 95366-9500 0 Change of Designated Operator Facility Phone N: 209-599-4141 1@ Update Certificate Expiration Date Designated UST ORerator(s)for this Facility PRIMARY Designated Operator's Name: JODY DEMELLO-RICE Relation to UST Facility(Check 0,;e) Business Name(ff d6ftrenifront above):Delta En"i-11110h1al Coissullants 13 Owner 0 Operator 0 Employee Designated Operator's Phone 9.- 916-402-3239 0 Service Technician 19 Third-Party International Code Council Certification#-5308678-UC Expiration Date:04/20/2009 ALTERNATE I(00dang) Designated Operator's Name; refer to backup documiwi Relation to UST Facility(Check One) Business Name(#differeatfrom aboiv): 0 Owner 0 Operator ®Employee Designated Operator's Phone#: refer to backup document 0 Service Technician 0 Third-Party International Code Council Certification#: refer to backup docusienr Expiration Daft:refer to backup docunjear ALTERNATE 2 (Opsional) DesignOperator's Namcr refer to backup docantent Relation to UST Facility(Check-One) Business Name(if dWerenrfronj above): Delta Environmental Consultants 0 Owner 0 Operator 0 Employee Designated Operator's Phone#: refer to bachap document 0 Service Technician IN Third-Party L International Code Council Certification#. refer to backup document Expiration Date: refer to backup docisment I certify that,for the facility indicated at::the 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): 5)kg J Inc SIGNATURE OF TANK OWNER: J&Larsen on behalf of Flying J inc. DATE: 12/02/2008 OWNER'S PHONE, SOL-_296-7899 NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:MM-wataftards-ca.99v/—UsttcontacMui)a a-ey–s-lam]. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. December 2008