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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(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 EI 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 /> Stockton Unified School District 10181573 <br /> Business Site Address City ZIP Code <br /> 1932 EI Pinal Drive. Stockton 95205 <br /> II. OWNER/OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> ❑ Owner Operator <br /> UST Owner/Operator Name Phone# <br /> Greg Kaiser, Stephanie Murphy, Marissa Murphy 209 887-2639 <br /> Mailing Address City State ZIP Code <br /> PO BOX 1058 Linden CA 1 95236-1058 <br /> III, 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 Re tions;Title 23,Division 3,Chapter 16;and any applicable local underground storage <br /> tank ordinances a facility identified above is in compliance with all applicable underground storage tank <br /> require <br /> Owner!Opera ignaiure ( 15 U 1211 9 ] //1' "�]� L Date <br /> / <br /> tfaA(/ t.lfrJiYOnW+�..1 4, I C'OM t a4 C' L5/-z'0-L� <br /> ID=Identification <br />