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• V <br /> San Joaquin County <br /> Environmental Health Department <br /> 600 E. Main Street Stockton CA 95202 <br /> Telephone(209) 468-3420 Fax(209) 468-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: GI Trucking dba Estes Express FacilityID#: <br /> Facility Address: 7611"S. Airport Way Reason for Submitting this Form(Check One) <br /> A 95206 ❑ Change of Designated operator <br /> Facility Phone#: 209-982-1841 9KUpdate Certificate Expiration Date <br /> Desianated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Ryan Burick Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714-893-6140 ❑ Service Technician Third-Party <br /> International Code Council Certification#:5 2 4 8 6 8 5-UC Expiration Date: 09/23/2010 <br /> ALTERNATE I donal <br /> Designated Operator's Name: Asa Cosby Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714-893-6140 ❑ Service Technician p/Third-Party <br /> International Code Council Certification#: 5252300-UC Expiration Date: 03/19/2010 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdiemnt from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page,-the individual(srlisted 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,I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print : k-sr(E-S <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 'S�"�g OWNER'S PHONE#: 20 9- ;9,6e <br /> November 2004 <br />