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AUG d B toes <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> cNT Ni is H <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:GI Trucking Cotnpany dba Estes Express Facility ID#: <br /> Facility Address: 7611 S.Airport Way,Stockton,CA 95206 Reason for Submitting this Form(Check One) <br /> X Change of Designated Operator <br /> Facility Phone#:209-982-1841 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Asa Cosby Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:714-893-6140 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:5252300-UC Expiration Date:3/19/2010 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above). ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Patty <br /> International Code Council Certification#: Expiration Date: <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, I understand and-M in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Mark Kozak,Estes Express Lines <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 8/25/08 OWNER'S PHONE#: 410-392-0328 <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.pov/ust/contacts/cupa azvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> NXvg %;a04 <br />