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6 0 <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#:8098 <br /> Facility Address: 1501 North Jack Tone Road Reason for Submitting this Form(Check One) <br /> Ripon,CA 95366-9500 X Change of Designated Operator <br /> Facility Phone#: (209)599-4141 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Refer to attached list of Certified Dos Relation to UST Facility(Check One) <br /> Business Name(If di,fJerent from above):Delta Environmental Consultants,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (800)477-7411 ❑ Service Technician X Third-Party <br /> International Code Council Certification#: Refer to attached list Expiration Date:Refer to attached list <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name:Travis Royce Relation to UST Facility(Check One) <br /> Business Name(If different from above):Flying J Inc. ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: (760)343-1500 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5249162-UC Expiration Date: 12/22/2006 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Donna Tompkins Relation to UST Facility(Check One) <br /> Business Name(If different from above): Flying J,Inc. ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: (209)3394066 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5252129-UC Expiration Date:08/25/2007 <br /> I certify that, for the facility indicated at the 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) - (f). <br /> Furthermore, except for historical data-gaps,to the best of my knowledge, based on <br /> representation made to me by persons directly responsible for gathering the information,I <br /> 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): Paul Siler <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 07/13/06 OWNER'S PHONE#: (801) 296-7700 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />