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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 eitl er the California Environmental Reporting System(CERS)or an equivalent local Unified Program Agency electronic <br /> reporti ig 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 /> [Califo nia Code of Regulations,Title 23,Division 3,Chapter 16,Section 2715(a).] <br /> Type of fiction <br /> ❑New Installation ❑Change of Ownership ❑Change of Operator <br /> I. FACILITY INFORMATION <br /> Busines Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> 4 !O"7 oo'z <br /> Busines.' Site ddress Cit <br /> y 9szi� <br /> II. OWNER I OPERATOR INFORMATION <br /> Relatiom;hip to Underground Storage Tank(s) <br /> ® Owner ❑ Operator <br /> UST Owvier/Operator Name Phone# <br /> jr/! Pd,-A, LL G 209- y77- SSSo <br /> Mailing ddress City State ZIP Code <br /> S'dGG44-ah <br /> 16A <br /> I I. CERTIFICATION BY OWNER/OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> I hereb/ certify that I understand the underground storage tank requirements of Health and Safety Code, Division 20, <br /> Chapte 6.i', 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 Ow ier/Operator Signature Date <br /> 9/za <br /> ID=I <br />