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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 />E New Installation E Change of Ownership El Change of Operator <br />I FACILITY INFORMATION Business Name (Same as Facility Name or DBA -Doing Business As) <br />Supervalu CERS ID <br />10181455 Business Site Address I City I ZIP Code I 1990 Piccoli Road 1Stockton ,95215 <br />II. OWNER / OPERATOR INFORMATION <br />Relationship to Underground Storage Tank(s) <br />0 Owner El Operator <br />UST Owner! Operator Name <br />Supervalu Phone # <br />(209) 931-7430 Mailing Address <br />1990 Piccoli Rd. <br />City <br />Stockton <br />State <br />CA <br />ZIP Code <br />95215 <br />III. CERTIFICATION BY OWNER I OPERATOR 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 requirements. <br />UST Owner perator Signaturer <br />frA . .1i-• AAJS— - - - <br />Date <br />ti -1 -7 - 2D <br />ID = Identification