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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 El Change of Ownership 0 Change of Operator <br /> 1. FACILITY INFORMATION <br /> Business Name(Same as Facility Name or DBA-Doing Business As) CERS ID <br /> St. Joseph's Medical Center 10181391 <br /> Business Site Address City ZIP Code <br /> 1909 Cemetary Lane Stockton CA <br /> II. OWNER/OPERATOR INFORMATION <br /> Relationship to Underground Storage Tank(s) <br /> 21 Owner ❑ Operator <br /> UST Owner/Operator Name Phone# <br /> David Ziolkowski 209-467-6384 <br /> Mailing Address City State ZIP Code <br /> 1800 N. California Street Stockton CA 95204 <br /> Ill. 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 a d that the facility identified above is in compliance with all applicable underground storage tank <br /> requirements. <br /> i <br /> USTOwn r/ pera r ignature i Date _ <br /> ID=Identification <br />