Laserfiche WebLink
VAr <br /> UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING-AND COMPLIANCE FORM (Page 7 of t ) <br /> Every underground storage tank (UST) facility must submit a one 41me 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 ❑ Change of ownership ❑ Change of <br /> g Operator <br /> L FACILITY INFORMATION _ <br /> IV <br /> Business Name (Sema as Facility Neme or D8A-Doing Business As) CERS ID <br /> A&A GAS & FOOD MART 10184191 <br /> Business Slte Address <br /> 1330E YOSEMITE AVE city zIP cone <br /> MANTECA 95336 <br /> II ` OWNER / OPERATOR INFORMATION - <br /> Relationship to Underground Storage Tank(s) <br /> 0 owner [3 operator <br /> UST Owner J Operator Name Phone # <br /> A&A GAS INC (209 ) 825-0332 <br /> Mailing Address City State I ZIP Code <br /> 1330E YOSEMITE AVE MANTECA CA 95336 <br /> IIL ' CERTIFICATION BY-OWNER' / OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> 1 hereby certify that 1 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 /> 11 /20/2021 <br /> r <br /> ID = IdentlAcatbn <br />