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Appendix X <br /> UNDERGROUND STORAGE TANK <br /> STATEMENT OF UNDERSTANDING AND COMPLIANCE FORM (Page i of i) <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 <br /> applicable.(California Code of Regulations,tit.23,div.3,ch. 16,§2715(a).) <br /> Type of Action ❑New Installation ❑Change of Ownership ❑Change of Operator <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as Facd#y Name or DBA—Doing Business As.) CERS ID <br /> : S T 1 191P3 L/3 <br /> Business Site Address C17 ZIP Code <br /> G r ST I I9s 2 i o <br /> II. OWNER I OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) er ❑Operator <br /> UST Owner/Operator Name Phone# <br /> �t �v \Tv = 2 Tv 6 H992-/�3S— <br /> Mailing Address Coy State ZIP Code <br /> cr19e obi cry Gc 4 I C� S3 '0 <br /> III. CERTIFICATION BY OWNER/OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> 1 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=ature Date <br /> i <br /> 9 30 <br /> CERS m California Environmental Reporting System,ID m Identification,UST v Underground storage tank <br />