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UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM (Page f 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 2715(a).] <br /> Type of Action <br /> ❑ New Installation El Change of Ownership U Change of Operator <br /> I . FACILITY INFORMATION <br /> Business Name (Same as Facility Name or ASA-Doing Business As) CERS ID <br /> PAQ INC . RANCHO SAN MIGUEL 10184805 <br /> Business Site Address City ZIP Code <br /> 610 S . CHEROKEE LN . ILODI 195240 <br /> li . OWNER J OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> ❑ Owner Operator <br /> UST Owner / Operator Name Phone # <br /> PAQ INC . RANCHO SAN MIGUEL ( 209) 339- 8200 <br /> Mailing AddressFLATHROP <br /> ity State ZIP Code <br /> 17935 MURPHY PARKWAY CA 195330 <br /> Ill . CERTIFICATION BY OWNER / 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 S nature Date <br /> 10/17/2019 <br /> ID = Identification <br />