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t <br /> UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM (Page of 1 ) <br /> operator <br /> n th he wrier <br /> perator <br /> ng that the owner or o <br /> Every underground <br /> and is intcomplian e nk w with all aapplicable UST require entsmust submit a eAtcopy of this atement d Damp eted form must be submitted ` <br /> understand licable. <br /> via either the California Environmental Reporting System (CE S) <br /> or an equivalent local Unified Program Agency electron►. <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 app <br /> [California Code of Regulations , Title 23, Division 3, Chapter 16, Section 2715(a) .1 <br /> ❑ Change of Operator <br /> Type of Action New installation E3Change of Ownership <br /> 1, FACILITY INFORMATION cells ID <br /> Business Name (Sameaas Facilit/yjNarn or DBA Donin�glBuslness As) i I n 6r � � <br /> rVal I �t !r ! L� 1 ZIP C de <br /> city OI <br /> Business Site Address ct —C)N <br /> i q l (� ✓Yl f� C <br /> 110 OWNER 1 OPERATOR INFORMATION <br /> Relationship to Underground Storage Tannk(s) (Dotpwner ❑ Operator <br /> L3 rT Phone # <br /> UST Owner / Operator Name <br /> City <br /> State ZIP Code <br /> Mailing Address <br /> 111 , CERTIFICATION BY OWNER I OPERATOR OF UNDERSTANDING AND COMPLIANCE : <br /> I hereby certify that I understand the underground storage tank requirements of Health and Safety Code, <br /> Division 20, <br /> Chapter 611 <br /> California Code of Regulations; ► ticompliance ter 6lelocal underground storage <br /> facility identified aboveis in with all appoableundergroudstoragetank <br /> tank <br /> odnances and that the <br /> requirements. Date <br /> UST Owner / Operator Signature <br /> I <br /> i_ <br /> i <br /> ID = Identification <br /> I <br />