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City <br />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 n New Installation LII Change of Ownership EIChange of Operator <br />FACILITY INFORMATION <br />Business Name (Same as Facility Name or DBA — Doing Business As) <br />,)fslm 'RI— _N V--Q \ c e <br />CERS ID <br />Business Site Address <br />Nen\n .CT <br />City ZIP Code <br />OWNER! OPERATOR INFORMATION <br />Relationship to Underground Storage Tank(s) 13 Owner LII Operator <br />UST Owner/Operator Name <br />Lo- `IbccoL\ <br />Phone # <br />Mailing Address <br />.-1,LN 3-3G, <br />l'712:Ck4-70•C\ <br />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 />ents. <br />Date <br />c.?1 <br />MAY 21 2021 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVIC ES <br />State Zip Code <br />CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage <br />tank