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CERSCalifornia Environmental ReporU»a System, ID =Identification, UST= Unde►nround storaae tank, ICC = International <br />IN IN 1 111 iiiiiiiiiiiiiiiiii� MISSION III illillillillill---- 11111 <br />UNDERGROUND STORAGE TANK <br />DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2 <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Designated UST Operator Inspection <br />10132636 <br />4-30-2020 <br />Business Name (Same as Facility Name or DBA-Doing Business As.) <br />FLYERS 487 <br />Business Site Address <br />City <br />983 MOFFAT BLVD <br />IMANTECA <br />=9'5336 <br />II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator (Print as shown on the ICC Certification.) <br />Phone # <br />Clent Gagnier <br />(530) 521 - 6818 Ext. <br />ICC Certification It <br />ICC Certification Expiration Date <br />5243792 <br />9-11-2020 <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. Vi11- NO SUMP OR LEAK ALARMS- MARKED AS N/A <br />2, <br />3. IX- SMALL AMOUNT OF LIQUID iN ALL SPILL BUCKETS- REMOVED TO HAZ DRUM- ISSUE CLEARED <br />4, <br />5, <br />6. X- NOT REQUIRED- MARKED AS NIA <br />7. <br />8. NO COMPLIANCE ISSUES <br />9, <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.compiiance 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 />All issue listed In section III above, must have a description of the follow-up action taken, or to be taken, to correct the Issue on the number fine that <br />corresponds with the number line the compliance issue is listed above in section 111. <br />2• <br />3. <br />4. <br />5, <br />6. <br />7. <br />8, <br />9. <br />10. <br />11, <br />12, <br />VI. OWNER I OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br />I have reviewed section Ill "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) <br />UST O%vner/0perator Signature <br />Date Signed <br />Code Council <br />