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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—Lodi Facility ID#: <br /> Facility Address: 15237 N.Thornton Road Reason for Submitting this Form(Check One) <br /> Lodi CA Change of Designated Operator <br /> Facility Phone#:209-339-4066 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Jody Demello-Rice Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:916-402-3239 ❑ Service Technician R Third-Party <br /> International Code Council Certification#:5308678-UC Expiration Date: 4/20/2009 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ® Employee <br /> Designated Operator's Phone#:refer to backup document ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:refer to backup document Expiration Date:refer to backup document <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to backup document ❑ Service Technician R Third-Party <br /> International 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,title 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): Flying J <br /> SIGNATURE OF TANK OWNER: <br /> �Jel Larsen on behalf of Flying J Inc <br /> Date: 10/28/08 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: htlp://www.waterboards.ca.gov/ust/contacts/ <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> October 2008 <br />