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UND ROUND STORAGE TANK SATEM OWNER STATEMENTS OF DESIGNATED UST OPERATO UNDERSTANDING OF AND COMPLIANCE WITH UST REQUI E® 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) NOV 2 2 2006 FACILITY NAME FACILITY PHONE LNVIRONMENT HEALTH Flying J Travel Plaza (209) 599-4141 PER fT/SE FACILITY SITE ADDRESS CITY 1501 North Jack Tone Road Ripon REASON FOR SUBMITTING THIS FORM(Check One): M Change of Designated Operator ❑Update of ICC Certification Expiration Date(s) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME: Refer to attached list of Certified DOS RELATION TO UST FACILITY(Check One) BUSINESSNAME(Ifdiiferentfromabove): Delta Environmental Consultants, Inc. ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE: (800)477-7411 ext. ❑ Service Technician M Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: Refer to attached list EXPIRATION DATE: ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: Eldon Riding RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdierentfrom above): Flying J Inc. ❑ Owner ❑ Operator M Employee DESIGNATED OPERATOR PHONE: (801) 725-4622 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: Locator: 1111 1 1 EXPIRATION DATE: 9/13/2008 ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATORNAME: Travis Royce RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdierentfromabove): Flying J Inc. ❑ Owner ❑ Operator ® Employee DESIGNATED OPERATOR PHONE: (760) 343-1500 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5249162-UC EXPIRATION DATE: 12/22/2006 ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATORNAME: Donna Tomplins RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifdierentfromabove): Flying J Inc. ❑ Owner ❑ Operator M Employee DESIGNATED OPERATOR PHONE: (209) 339-4066 ext. ❑ Service Technician ❑ Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5252129-UC EXPIRATION DATE: 8/25/2007 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, except for historical data-gaps, to the best of my knowledge, based on representation made to me by persons directly responsible for gathering the information, I understand and am in compliance with the requirements (statuses, regulations,and local ordinances)applicable to underground storage tanks. TANK OWNER NAME: Paul Siler TANK OWNER TITLE: Environmental Director of Retail Ops. OWNER PHONE: (801) 296-7899 TANK OWNER SIGNATURE: DATE: November 20, 2006 INSTRUCTIONS 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC).ICC certification information is available on-line at: www.iccsafe.org/e/certsearch.html.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs.Unidocs member agency jurisdictions and contact information are listed on-line at: www.unidocs.org/members/whoregulateswhat.htmi. Contact information for other local agencies within California is available at: www.swrcb.ca.gov/cwphome/usttcontacts/docs/local_agency_list.xis. 3. 23 CCR§2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change.