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t <br /> lam <br /> UNI )CRGRtIUNU ; T( 1RnGl <br /> UNDERGROUND STORAGE TANK UPLRA InNK <br /> 1 11 I ) R VI !AJAI III t . ( ION REPO RT lN ,, I „t <br /> f /1t ; IlITYINIrI <br /> RMA 11 / 1N <br /> Jdl' Nanln IIA Ihunllt'u inn. _ . A41I <br /> rib ` tr <br /> DESIGNATED UNDERGROUND STORAGE. TANK t) F I` NA II M III rIFtM / FIrrN <br /> „r . alRdh.; t ( II )VI]allol�(I'rir ns .. hewn r�R lhu /CG Ge+rtlhc � thun ! . <br /> III . COMPLIANCE 1 fJ <br /> N.or p " in sections VIl through XI must bo explained I <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION _ <br /> icertity that the visual inspection was perfor ed in II compliance with California Code of Regulations , Title 23, <br /> :lq chapter 16, Section 2716 and all the inf tion ided herein Is accurate. <br /> al I operator Signature <br /> V. OWNER / TOR DES PTION OF FOLLOW-UP ACTIONS <br /> LtsWed in Section 11/ above must have cription of the f w-up action taken or to be taken to correct the issue on the number <br /> VMsponds with the number line of pliance issue led above in Section 111. <br /> V N LEDGMENT OF COMPLIANCE ISSUES <br /> wed Section Ill " o a description in Section V of the action taken or to betaken <br /> I : the issues d(scov ` Da���Vn� <br /> ai aWnerl es di or (P ' - tor Signature / � J � — <br /> T tier- <iCaieCofxte3 <br /> V <br /> � r �nhlR9Pottin9Syts] an . <br /> UST Storms r <br />