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UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM (Page 1 of 1 ) <br /> _ <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 clays 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 2716 (a) .] <br /> Type of Action <br /> ❑ New Installation ❑ Change of Ownership ❑ Change of Operator <br /> I . FACILITY INFORMATION <br /> Business Name (same as Facility Name or DBkDoing Business As) ]CERS ID <br /> Wi <br /> Bus[ ess Site Address <br /> City ZIP Code <br /> i� L ✓L�f , �' �� 6th Zo(� <br /> II . OWNER I OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> ❑i "Owner ❑ Operator <br /> UST Owner / Operator Name Phone # <br /> Mailing Address Cily Slate ZIP Code <br /> V'(EUvk L& A& )U4 L100 Sfi� �Iov/1 GA qDz Gl <br /> III . CERTIFICATION BY OWNER / 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 / 0 orator S <br /> ign <br /> atureDale <br /> AkI <br /> ID = Identification V ro latI V ` t: I I <br /> 2(� 7/ <br />