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i <br /> UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM (page t 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 ❑Change of Ownership ❑Change of Operator <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facilky Name or DBA-Doing Business As) CERS ID <br /> ABC PETROLEUM INC, 10182109 <br /> Business Site Address City Z1P Code <br /> 2375 N. TRACY BLVD TRACY 96376 <br /> II. OWNER!OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> D Owner © Operator <br /> UST Owner 1 Operator Name Phone# <br /> HAKAM S MISSON (925) 915-0805 <br /> Mailing Address City State Z!P Code <br /> 6951 SOUTHFRONT RD TLIVERMORE CA 94651 <br /> Ill. CERTIFICATION BY OWNER!OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> I 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 I Operator Signature Cate <br /> - 1/14/2021 <br /> II <br /> I <br /> i <br /> 0=Ider l cation <br />