Laserfiche WebLink
. .. .._Jill,w—� <br /> Jim I <br /> Jill 11 <br /> UNDERGROUND STORAGE TANK , <br /> JillSTATEMENT OF � 1 LR%5TANNII.ING ANI) Ct}ip PL.1Ai JCE. F- OfEt'm (oage -1 of i) <br /> Every underground storage tank (UST) facility must submit a one-time statement indicating that the owner or operator <br /> understands and is compliance nwith <br /> al aapplicable <br /> orti g Sys <br /> a UST requirements, A ropy of this completed form must be submitted <br /> via either the California Environmental Reporting System (GFRs) or an equivalent Local Unified Pr <br /> cWarn reporting portal within 30 days of: 1 ) an installation of a UST; or 2) a change in owner or operator she IJST, as ape p1(cafJtec <br /> [California Code of Regulations, Title 23, Division 3, Chapter 16, Bastion 271 �a}.] <br /> Type of Action <br /> ['j New Installation 13 Change of Cumersh3p <br /> 0 Change of Operator <br /> Jill <br /> Business Name l5ama zs FaCilrry Hama or O8Business As) 1>! kT11�A1 <br /> CSRS iD <br /> s site <br /> "?AG�� - _ � i.. ' � ZIP Code <br /> ` � <br /> if. ED1tVR 11 t} tt� q52 <br /> - RIlT(CiC51 . .. <br /> Relationship to Underground Storage Tank{s) <br /> Owner © Operator <br /> t35T Oumer I Operator Name <br /> hone # <br /> Mailing AddressG� <br /> 1B MoCry. \ <br /> i �>n i� 1 W <br /> Stale ZIPCode <br /> t ` <br /> cel Ti iMalc <br /> l�TtoN t <br /> OWN ER10PERAT0K nR tjmn%=bS ARDIN40AND .co <br /> I hereby certify that i understand theunderground storage tank requirements of Health and Safety Code, Division 20, <br /> Chapter 6.77 Califomia 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 nil applicable underground storage Yank <br /> IJ4 4 (?urnerl (}peratic r Signo�� <br /> iVolGate <br /> 5 25 <br /> i <br /> +n w ldentt <br /> E <br /> UN99 <br /> Www.unidoes arg <br /> 9f9 • Rev. A6194198 <br />