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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) CERS ID <br /> COSTCO 1091 10146151 <br /> Business Site Address City ZIP Code <br /> 2680 REYNOLDS RANCH PKWY LODI 95240 <br /> II. OWNER!OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> ® Owner El Operator <br /> UST Owner/Operator Name Phone# <br /> Costco Wholesale Corp 425-313-8100 <br /> Mailing Address City State ZIP Code <br /> Costco Licensing P.O. Box 35005 Seattle �WA 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 Date <br /> rl �/}/ 12/27/2018 <br /> ID=Identification <br />