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Appendix XIII <br /> UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Page 1 of 2 <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Desiqnated UST Operator Inspection <br /> 10165815 1 10/01/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> 7-Eleven 17334 <br /> Business Site Addres City Zip Code <br /> 4501 N. PERSHING AVE STOCKTON 95207 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) Phone Number <br /> Mark Rasmussen (949)460-5200 <br /> ICC Certification# ICC Certifi tion Expiration Date <br /> 8867893 12/27/2019 <br /> III. COMPLIANCE ISSUES <br /> All answer of"N"or"NA"in sections VII through XI must be explained in this section and may require follow-up action <br /> 1. Site has double-walled lines. <br /> 2. Site has double-walled tanks. <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> hereby certify that the visual inspection was performed in full compliance with California Code of Regulations,title 23, <br /> division 3, chapter 16, section 2716 and all the information provided herein is accurate. <br /> Designated UST Operator Signature <br /> V. OWNER/OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> 1. No follow-up required. <br /> 2. No follow-up required. <br /> VI. OWNER/OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> I have reviewed section III "COMPLIANCE ISSUES"and provided a description in section V, of the action taken or to be taken <br /> to correct the issues discovered <br /> Name of UST Owner/Operator(Print) LIST�perator Signature D e Si ned <br /> CERS=Cal ifomiaEnvironmental Reporting System.ID=Identification UST=Underground storage tank ICC=International Code Council <br />