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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 El Change of Ownership El Change of Operator <br /> I . FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA-Doing Business As) CERS ID <br /> Pilot Travel Centers , LLC 10182131 <br /> Business Site Address City ZIP Code <br /> 1501 N Jack Tone road Ripon 95366 <br /> II . OWNER / OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> El Owner Operator <br /> UST Owner / Operator Name Phone # <br /> Pilot Travel Centers , LLC ( 865 ) 474-2826 <br /> Mailing Address City State ZIP Code <br /> 5508 LONAS RD Knoxville TN 37939 <br /> III . CERTIFICATION BY OWNER / OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> hereby certify that 1 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 / Opera or"8ig tore/ Date <br /> ID = Identification <br />