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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 <br /> owner or operator understands and is in compliance with all applicable UST requirements . A copy of <br /> this completed form must be submitted via either the California Environmental Reporting System <br /> ( CERS ) or an equivalent local Unified Program Agency electronic reporting portal within 30 days of: <br /> 1 ) an installation of a UST ; or 2 ) a change in owner or operator of the UST , as applicable . <br /> [ California Code of Regulations , tit . 23 , div . 3 , ch . 16 , §2715 ( a ) . ] <br /> Type of Action ❑ New Installation ❑ 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 /> 'Q \ CCS � \ 0 <F I 'Z <br /> Business Site Address City ZIP Code <br /> YY1 v) \ S i v S � � c1 `to V <br /> II . <br /> OWNER / OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank( s ) ER Owner ❑ Operator <br /> UST Owner/Operator Name Phone # <br /> L0I �VbCL0Li 52Gcv>j (4iZRse �76�7 <br /> Mailing Address <br /> City State Zip Code <br /> (204 1 Or ? <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 <br /> Safety Code , division 20 , chapter 6 . 7 , California Code of Regulations , title 23 , division 3, <br /> chapter 16 , and any applicable local underground storage tank ordinances and that the <br /> facility identified above is in compliance with all applicable underground storage tank <br /> e u ents . <br /> UST OweOperator Sigin4peture Date <br /> � l vmwl <br /> CERS = California Environmental Reporting System , ID = Identification , UST = Underground storage <br /> tank <br />