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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 understands and is in <br /> compliance with applicable UST requirements.A copy of this completed form must be submitted via either the California Environmental Reporting <br /> System(CERS)or an equivalent local Unified Program Agency electronic reporting portal within 30 days of.1)an installation of a UST;or 2)a change in <br /> owner or operator of the UST,as applicable,(California Code of Regulations,Title 23,Division 3,Chapter 16,Section 2715(a).) <br /> Type of Action ® New Installation ® Change of Ownership ® Change of Operator <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> CHEVRON STATION#208117 10182313 <br /> Business Site Address City Zip Code <br /> 755 S TRACY BLVD TRACY, CA 95376 <br /> II. OWNER/OPERATOR INFORMATION <br /> Relationship to Tank(s) ® owner ® Operator <br /> UST Owner/Operator Name Phone# <br /> Chevron Products Company(a Division of Chevron U.S.A. Inc.) 925-842-9002 <br /> Mailing Address CCS State ZIP Code <br /> P.O. Box 6004 Attn: Permit Desk San Ramon CA 94583 <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,chapter 6.7,California Code of <br /> Regulations,title 23,division 3,chapter 16,and any applicable local underground storage tank ordinances and that the facility identified above is in <br /> compliance with all applicable underground storage tank requirements <br /> UST Owner/Operator Signature Date <br /> I/ . ,. r-. 12/6/2018 <br />