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Jun 02 20 , O3 , O2p p • 4 <br /> _ . ._ . . <br /> UNDERGROUNDSTORAG <br /> �sTATEmE!i4T oF -uNDr=FtorANt)i a ANt) comp ANGrm I=DI (Wage , oft}. <br /> Every underground storage tank (UST) facility must submit a one-time statement indicating that the owner or operator <br /> understands and is in compliance with all applicable U$T requirements. A copy of this completed farm must be submiEted <br /> via either the California Environmental Reporting System (CERS) or an equivalent local Unified Program Agency electronic <br /> reporting portal within 30 slays of: 1) an installation of a UST; ort; a change in owner or operator of the UST, as applicable* <br /> [California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2715(a).] <br /> Type ot•Action New Installation <br /> Q Change of Ownership © Change of Operator <br /> 1, FACM11TY INFORMATION <br /> I3ys;ness Name {Same as Faer'lity Marna or +JBA -DoOg Business As) CERS <br /> ess Site Ald ,ss ulyZIP ZIP Cod <br /> tl. Ov`NI R t 004RALTOR INFORMATION <br /> Relationship to Underground S!orage Tank(s) <br /> Operator � <br /> UST Owner J Operator Name <br /> 10et 3l — $2 <br /> Ma�ir� Address City State ZIP Code <br /> C£RTI tPA'f M BY OWNER 10KRATIOR OF, t11+#DEk$aTWOING . COMPLIANCE <br /> I hereby certify that I understan6 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; nd any applicable local pnderground storage <br /> tank ordinances and that the facility identified above Is In compliance wth all applicable underground storage tank <br /> requirements. <br /> j U 0wnerl operator Signature pate <br /> IU �ldentifi:xtt�n 4 <br /> Mol vnvwmnldoes.org Ill vRev. 06114118 <br />