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UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM (Page 1 of 1 ) <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 UST requirements . A copy of this completed form must be submitted <br /> via either the California Environmental Reporting System (CERS) or an equivalent local Unified 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 x Initial Upload❑ p El New Installation ❑ Change of Ownership ❑ Change of Operator <br /> I . FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br /> YRC Inc 10181485 <br /> Business Site Address City I ZIP Code <br /> 1535 E Pescadero Ave Tracy 195304 <br /> II . OWNER / OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> ❑ Owner (] Operator <br /> UST Owner / Operator Name Phone # <br /> YRC , Inc 1 (209) 833- 1500 <br /> Mailing Address City State ZIP Code <br /> 1535 E Pescadero Ave Tracy CA 95304 <br /> Ill . CERTIFICATION BY OWNER / OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> I hereby certify that I 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 Owner / Operator Signature Date <br /> i <br /> i <br /> ID = Identification <br /> E UN-110 www.unidocs.org 1/1 - Rev. 06114/16 <br /> I' <br /> i <br />