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E G D ST 'TNTC <br /> STATEMENT F N STANDING AND COMPLIANCE ge 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 Change of Ownership El Change of Operator <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as Facility Name gr DBA-Doing Business As) CERS ID <br /> ' I <br /> Business Site dress City ZIP Cade <br /> E e— VACS 76 <br /> 1I. OWNER I OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) ® owner ® Operator <br /> UST Owner/Operator Name Phone# <br /> ay ��� l'� c ,� 16 �- f <br /> Mailing Address y City State ZIP Code <br /> '6Q�B ` —T 1 (7,4- 5-3 ..7 � <br /> Ill. 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 <br /> requirements. <br /> UST Owner/Operator Signature Date <br /> ID=Identification <br />