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Appendix X <br /> 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 (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 <br /> applicable . (California Code of Regulations , tit . 23 , div. 3 , ch . 16 , §2715 (a). ) <br /> Type of Action El New Installation D Change of Ownership ❑ Change of Opera r <br /> X/S <br /> I . FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA — Doing' Business As.) CERS ID <br /> r <br /> Business Site A ress CA l City ZIP Code <br /> a? 0z aaaal <br /> II . OWNER / OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) Owner Operator <br /> UST Owner/Opercr or Name Pho ii <br /> = <br /> ( r- � o <br /> Mailing Address City state <br /> � /ZIP <br /> �Code <br /> mom � ` <br /> P (/T/�r 1Y , ) v <br /> 111 . 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/Operator Signature Date <br /> 2 <br /> = I ntification UST = Underground storage tank <br /> CERS = California Environmental Reporting System, ID de <br />