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2020 - 02 - 19 080421 Diesel 223 2095993680 > > Loves P 1 /4 <br /> UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br /> iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliilillillilillillillillillillillilliillillillillillillilliillillillillillillilliillillill - <br /> 1 . FACILITY INFORMATION <br /> CERS ID Data of Doslgnatod UST Operator Inspection <br /> 10184317 12/26/2019 <br /> business Nome (Same as Facility Name or DBA•Dotng 9usiness As) <br /> Love's Country Stores of California #223 <br /> BuslnoaS Site Atftfrgss City ZIP Coda <br /> 1553 W: Colony Road <br /> Ripon 95311 <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the 1CC Certification.) Phone # <br /> Kevin Dutra (949) 4604200 <br /> ICC Certification u ICC Cortirication Expiration Date <br /> 9273805 7/29/2021 <br /> Ill, COMPLIANCE ISSUES <br /> AllanswdrS of wNw or "NA " in sections V11 through X1 must be explained in this section and may require follow-up action. <br /> 1 . Site has double-wailed tanks. <br /> IV, CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> I 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 l <br /> V. OWNER / OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issues listed in Section tit above must have a description of the follow-up action taken or to betaken to correct the &ue on the number <br /> line that corresponds with the number line of the compliance issue listed above in Section III. <br /> 1 . No follow-up required. <br /> OM*�111 IM <br /> vi. OWNER / OPERATOR ACKNOWLEDGMENT OF COMPLIANCE issues <br /> I have reviewed Soogon 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 /> Nam4 Of UST t?wnerlpperator (Punt) U Slgnolure Date Signed <br /> CERS ■ Calffomin Environments! Reporting Syd4ny, 10 ,t kkinffiotion, UST ■ StoriwTa* IGC ■ Intomationat Code Cbumit <br /> VIVO <br /> 0/1 �,gli =.C/ <br />