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UNDERGROUND STORAGE TANK <br /> F7ERS <br /> ' ATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2 ► <br /> 1 . FACILITY INFORMATION Date of Designated UST Operator Inspection <br /> 10/ 18/2019 ___----- <br /> 10181653 t <br /> Business Name (same as Facility Name or DBA-Doing Business As.) z <br /> CSI -201761 / 1561 -CHV ZIP Code <br /> Business Site Address City 95337 <br /> 1103 S Main ST Manteca <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification.) <br /> Phone # <br /> Erick Aranda {561 ) 235 - 8833 Ext . <br /> ICC Certification # -- -- ICC Certification Expiration Date <br /> 8211754 03/ 12/2021 <br /> III, COMPLIANCE ISSUES <br /> All answer of `N" or 'NA " in sections V/l through Xl must be explained in this section and may require follow-up action. <br /> 1 . VI1 . 1 - No follow up pendingfrom previuos visit <br /> 2 . VI11 . 2 . 3 - No leak or sump alarms during this period e G <br /> 3 . IX . 1 - DO found , removed and properly discarded approximately 64oz of liquid from 91 STP sump <br /> 4 . II - Found debris inside all spill buckets <br /> 5 . X . 5 . 6 - Line or Tank tightness test not require <br /> 6 . <br /> 79 <br /> 8 . <br /> 9 . o �- <br /> 10 . <br /> 11 . <br /> 12 . <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 's curate . <br /> Designated UST Operator Signature <br /> V. OWNER / OPERATOR DESCRIPT N OF FOLLOW-UP ACTIONS <br /> All issue listed in section 111 above, must have a description of the follow-up ac on taken, or to be taken, to correct the issue on the number line that <br /> corresponds with the number line the compliance issue is listed above in se ion 11I. <br /> 1 . IX . 2 - Store personnel to remove debris from spil ckets during daily. routine inspection <br /> 2 . X . 5 . 6 - No follow up required . <br /> — - i <br /> 3 . Pi <br /> 4 . <br /> 5 ± AIN Ilt ( tA NIIaN I . oL, IIIAAA L; I II <br /> 6 . 1 ) F1 SIL \ <br /> 7 . t <br /> 9 . <br /> 10 . <br /> 11 . <br /> 12 . <br /> VI . OWNER ! OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> rha e reviewed section III " COMPLIANCE ISSUES " and provided a description in section V, of the action taken or to be taken <br /> orrect the issues discovered . <br /> e of UST Owner/Operator (Print) — — Date Signedstal Bailor uS r/o ato si re <br /> -- - _ <br /> 10/ 182019 <br />