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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Page 1 of 2) <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10156809 12/9/19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> SAFEWAY 1769 <br /> Business Site Address 1 City ZIP Code <br /> 2802 COUNTRY CLUB BLVD 'STOCKTON 95204 <br /> il. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) Phone# <br /> Rita Martinez 408-971-2445 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9028811 1/25/21 <br /> Ill. COMPLIANCE ISSUES <br /> All answers of'N"or'NA"in sections Vll through XI must be explained in this section and mayrequire follow-up action. <br /> 1. TLS CURRENTLY:ALL FUNCTIONS NORMAL <br /> 2. NO NEW ALARMS TO REPORT THIS PERIOD <br /> 3. <br /> 4 <br /> 5• <br /> 6. <br /> i <br /> 7. <br /> 8. <br /> 9. <br /> .. 10 <br /> � 11. <br /> 12. TANK/UNE TIGHTNESS TESTING NOT REQUIRED <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 <br /> V. OWNER/OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issues listed in Section/ll above must have a description of the follow-up action taken or to be taken to correct the issue on the number 1 <br /> line that corresponds with the number fine of the compliance issue listed above in Section 1/1. <br /> 1. <br /> _._.. <br /> 2. _ r <br /> 3. <br /> �_. 4 <br /> s. <br /> 6. <br /> .__.._._.. ., <br /> (.. <br /> 8. <br /> _9. <br /> 10. <br /> 12. <br /> VL OWNER/OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> 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) UST Owner/Operator Signature Date Signed <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code CounciI <br />