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Appendix X <br /> 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 <br /> owner or operator understands and is in compliance with all applicable UST requirements. A copy of <br /> this completed form must be submitted via either the California Environmental Reporting System <br /> (CERS) or an equivalent local Unified Program Agency electronic reporting portal within 30 days of: <br /> 1) an installation of a UST; or 2) a change in owner or operator of the UST, as applicable. <br /> [California Code of Regulations, tit. 23, div. 3, ch. 16, §2715(a).] <br /> Type of Action ❑ New Installation ❑ Change of Ownership IP/Change of Operator <br /> I. FACILITY INFORMATION <br /> Business Name (Same as Facility Name or DBA — Doing Business As) CERS ID <br /> EPA <br /> Business Site Address City ZIP Code <br /> 180n L,►POMIA SMM-T 5TO CXTO �j 9 Slog <br /> II. OWNER /OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) I/bwner ❑ Operator <br /> UST Owner/Operator Name Phone # <br /> DCA W1 uo/ -2-99 (O's$ <br /> Mailing Address <br /> X013 06f W W � St <br /> City State Zip Code <br /> 'bT k'T0 4 CA, 9. 5210q <br /> III. CERTIFICATION BY OWNER 1 OPERATOR OF UNDERSTANDING AND COMPLIANCE <br /> hereby certify that 1 understand the underground storage tank requirements of Health and <br /> Safety Code, division 20, chapter 6.7, California Code of Regulations, title 23, division 3, <br /> chapter 16, and any applicable local underground storage tank ordinances and that the <br /> facility identified above is in compliance with all applicable underground storage tank <br /> requirements. <br /> UST O er/Op r for S' nat re Date <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage <br /> tank <br />