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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 (C ERS) 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 2715(a).] <br />Type of Action <br />❑ New Installation El Change of Ownership ®Change of Operator <br />I. FACILITY INFORMATION <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />CERS ID <br />COSTCO 1091 <br />10146151 <br />Business Site Address <br />City <br />ZIP Code <br />2680 REYNOLDS RANCH PKWY <br />LODI <br />95240 <br />II. OWNER ! OPERATOR INFORMATION <br />Relationship to Underground Storage Tank(s) <br />® Owner El Operator <br />UST Owner / Operator Name <br />Phone # <br />Costco Wholesale Corp <br />425-313-8100 <br />Mailing Address <br />City <br />State <br />ZIP Code <br />Costco Licensing P.O. Box 35005 <br />Seattle <br />�WA <br />98124 <br />III. CERTIFICATION BY OWNER 1 OPERATOR OF UNDERSTANDING AND COMPLIANCE <br />1 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 <br />Date <br />rl }/ <br />12/27/2018 <br />�/ <br />ID = Identification <br />