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1 <br /> Y-7_s <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name.- FLYING J TRAVEL PLAZA Facility ID M 10431 <br /> Facility Address: 15237 THRORNTON ROAD Reason for Submitting this Form(Check One) <br /> IMDI,CA 95242-9321 0 Change of Designated Operator <br /> Facility Phone#: 209-3394066 <br /> — ® U to Certificate Expiration Date <br /> Designated UST ODer2tor s for thILEacifl <br /> PRIMARY <br /> Designated Operator's Name: JODY DEMELLO-RICE Relation to UST Facility(Chock One) <br /> Business Name(1fd(#eramtfmm,abovw):Delta En Wromneistal COAR111aflis <br /> 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#- 916402-32-49 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:5308678-UC Expiration Date:04/20/2009 <br /> AMTERNATE I(Optipmaj) <br /> Designated Operator's Name: refer to backup document Relation to UST Facility(Check 011e) <br /> Business Name(if dWerentfram above): 0 Owner 13 Operator ®Employee <br /> Designated Operator's Phone#: refer to backup deenvielm, (3 Service Technician 0 Third-Party <br /> International Code Council Certification#: refer to backup document <br /> Expiration Date:refer to backup document <br /> ALTERNATE 2 (optional) <br /> Designated Operator's Name: r4&x to backup darutnent Relation to UST Facility(Check One) <br /> Business Name(if dfficrentfrmi above): Dedia Environmental Consithants 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: refer 10backup document 0 Service Technician IN Third-Party <br /> International Code Council Certification#-, refer to backup decumezrot Expiration Date. refer to backup document <br /> I certify that,for the facility indicated at Ale top Of this page, the individual(s)listed above will <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23,section 2715(c)-(0. <br /> Furthermore,I understand and-am in Compliance with the requirements(statutes, <br /> regulation I s,and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print)- E!yjalz J Inc. <br /> SIGNATURE OF TANK OWNER- <br /> DATE: Jeff Larsen on behalf of Flying J Inc. <br /> OWNER'S PHONE 801-296-78" <br /> NOTE:1)SUBMIT THIS COMPLETED FORK TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> ARESOURCES CONTROL BOARD)By JANUARY 1,2005-THE LOCAL AGENCY LIST IS AVAILABLE <br /> T: <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO TIM MORMATION WITHIN 30 DAPS <br /> Or,THE CHANGE. <br /> December 2008 <br />