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MAY-16-2007 WED 1111 AM WEST OIL LLC FAX NO. 80 P. 02 UNDERGROUND STORAGE TANK S'Y'STEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUMEMENTS For use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited; Title 23, Div.3, Ch, 16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Flying J Travel Plaza (209) 339-4066 TACiErrY$)TtI ADDWS CITY 15237 Thomton Road Lodi REASON FOR SUBMITTING THIS FORM(Check One)! ®Change of Designated Operator ❑Update of ICC Certification Expiration Dates) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OKKATOR NANIF; Refer to attached list of Certified DOs RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdiff,-rentfromgbow): Delta Environmental ConSultantS, InC. ❑ Quer ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (800)477-7411 ext. ❑ Service Technician Third-Party INTERNATIONAL CODE COUNCIL CERTIFICA'T'ION NO.; Refer to attached list EXPIRATION DATE: ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY O tional DESIGNATED OPERATOR NAME; Travis Royce RELATION TO UST FACILITY(Check One) BUSINESS NAME(ljdj#erentfromabwe)! Flying J Inc. Downer ❑ Operator J@Fmployee DESIGNATED OPERATOR PHONE: (760)343-1500 ext. ❑ Service Technician ❑ 'rhird-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5249162-UC EXPIRATION DATE; 12/12/2008 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Opdonal) DESIGNATED OPERATOR NAME; Donna Tompkins RIrLATION'I'O UST FACII.rrY((:heck one) BUSINkiSS NAME(4f d(Qersnlfromabove): Flying J Inc. ® owner ® Operator M Employee DESIGNATED OPERATOR PHONE: (209)339-4066 ext ❑ Service'Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL.CEKTIFICATION NO.; 525129-UC EXPIKATION DATE; 8/25/2007 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Oplimnal) DESIGNA'T'ED OPERATOR NAME: Eldon biding RELATION TO UST FACILITY(Check One) BUSINESS NAME(1fdiferent romabove); Flying J Inc. [] Owner [I Operator ® Employee DESIGNATED OP4RATOR PHONE: (801)725-4622 ext. ElService Technician E] Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: Locator: RI K01 11 1 EXPIRATION DATE: 613/2008 I certify that, for the facility indicated at 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)through (f). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Jeff Larsen TANK OWNER TITLE: Director of Health, 84fety& Environment OWNER PHONE: (801)296-7700 TANK OWNER SIGNATURE: ��— DATE: 05/16/2007 _q0&rrISTRUcTIONs I. Report the name(s)of the Designated UST Operators)as registered with the International Codw Council(ICC). ICC certification information is available on-line at: www,iccSRfe.org/e%ertwarch.htmi.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidoes member agency jurisdictions and contact information are listed on-line at: wwew.unidoes.org/members/whoregulateswhsit.htmi. Contact information for other local agencies within California is available at:www.swrcb.ca.gov/ewPhOmc/usVcontacts/doesAocal–agencyjistxls. 1 23 CCR§2715(x)requires that you notify the local agency of any changes to this information within 30 days of the date of change. IIN•062.1n www.uaidocxarg o9n.2/os