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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 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 applicable. <br /> [California Code of Regulations,Title 23,Division 3,Chapter 16,Section 2715(a).] <br /> Type of Action <br /> ❑New Installation ❑Change of Ownership hangs of Operator <br /> I. FACILITY INFORMATION <br /> Business Name(Same as Facility Nam BA-Doing Business As) CERS ID <br /> Business Site Address a�U f <br /> ( F f� 2 �it''� �Code <br /> 6 <br /> II. OWNER/OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> Owner R115peretor <br /> UST Owner/Operator Name PhonnNE <br /> e#Maili - i <br /> ng Address79W 1 <br /> C ZIP% <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/Operator Signature Date <br /> ID=IderfCation <br />