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i <br /> UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM (page 1 of 1 ) <br /> Everyunderground storage tank ( UST) facility must submit a one4lme statement indicating that the owner or operator <br /> understands and Is In compliance with all applicable UST requirements. A copy of this completed form must be submitted <br /> via either the California Environmental Reporting System (CERS) or an equivalent local Unifled Program Agency electronic ` <br /> reporting portal within 30 days of: 1 ) an installation of a UST; or 2) a change In owner or operator of the UST, as applicable< <br /> [California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2716(a).] <br /> Type of Action Q New installation 0 Change of Otmerahlp O Change of Operator <br /> i. FACILITY INFORMATION <br /> Business Name (Same as Faclllty Name orDBAoDo1ng Business As) CERS ID <br /> Sutter Valley Hospitals dba Sutter Tracy Community Hospital 10397599 <br /> Business Site Address city ZIP Code <br /> 1420 N Tracy Blvd Tracy 95376 <br /> Il. OWNER / OPERATOR INFORMATION <br /> Relatlonshtp to Underground Storage Tank(s) 0 owner © Operator <br /> UST Cramer 1 Operator Name Phone # <br /> AffordaJest (209 ) 744-0112 <br /> Mailing Address City Stale zIP Code <br /> 416 2nd Street Gait CA 95632 <br /> Ill . CERTIFICATION BY OWNER ! OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> I hereby certify that 1 understand the underground storage tank requirements of Health and Safety Code, Division 20, <br /> Chapter 6.7, California Code of Regulations; Title 23 , Division 3, Chapter 16 ; and any applicable local underground storage <br /> tank ordinances and that the facility Identified above Is In compliance with all applicable underground storage tank <br /> requirements. <br /> UST Ovine t Operator Signature Dale <br /> 2/7/2020 <br /> 1 <br /> j lD � idero�atton � <br /> I <br /> i I <br /> I <br /> j <br />