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Nov- 14. 2018 4:30PM No. 2487 P. 4 <br /> 'UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM(Paget oti) <br /> Every underground storage tank(07)fac/IW must submit a one-time statement Indicating that the owner or operator <br /> understands and Is In compliance with off applicable usr requirements. A copy of this completed form must be submitted <br /> via either the Caffforrila 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 <br /> applicable.(California Code of Regulations,fit.23,div.3,ch.16,§2716(e).) <br /> Type of Action Lj Now Installation [I Change of Ownership ❑Change of Operator <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as Foolffly Name or DBA-Doing Business As.) CERS ID <br /> L W f--),-J--r e4 - I IQ/ � <br /> Business Vts Address city IP Code <br /> 7 <br /> MA <br /> TION <br /> OWNER I dPERATOA INFO MATION <br /> Relationship to Underground Storage Tank(s) ^75( <br /> er LJ Operator <br /> bm <br /> UST Owner/Operator Name IPhone# <br /> LOD= C)n 4,40 0 L J�t4 1 A <br /> City <br /> Mailing Address . state f ZIP Code <br /> :7 )CCM1.1 ryl r1c) rA- <br /> Ill: CERTIFICATION BY OWNER 0 <br /> PERATOR,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 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/Operator Signature Date <br /> '-Ail r)I <br /> 49 <br /> RECEIVED <br /> N'OV 15 2018 <br /> ENMRONNAIENTAL <br /> ray <br /> DEPART WNIT <br /> CERS in California Environmental Reporting System,ID=Identification,UST=Underground storage tank. <br />