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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 /> ADELFO'S ARCO AMIPM 10830655 <br /> Business Site Address City ZIP Code <br /> 3443 CHEROKEE ROAD STOCKTON 95205 <br /> II. OWNER I OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) ® Owner ® Operator <br /> UST Owner/Operator Name Phone # <br /> ADELFOS INC 209-601-7292 <br /> Mailing Address <br /> 13899 N DEVRIES RD <br /> City j State Zip Code <br /> LODI I CA 95242-9427 <br /> Ili. 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 /> re u <br /> irementA. <br /> UST Own f pe r i tore Date <br /> 111412022 <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage <br /> tank <br />