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`1 <br /> UNDERGROUND STORAGE TANK <br /> D SIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br /> I . FACILITY INFORMATION <br /> (� / to of Designated UST Operator Inspection <br /> CERS IDqq <br /> I b <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> 76- March Lane ZIP Code <br /> Business Site Address City <br /> Stockton 95210 <br /> 1916 March Lane <br /> II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designate d USTerator (Print as shown on the Icc Certification.) Phone # <br /> t r f.0-f i a ' •L/ / zr/� <br /> ICC Certification # ICC Certification Expiration Date <br /> III . COMPLIANCE ISSUES <br /> All answers of,. "N" or "NA" in sections VII through XI must be explained in this section and may require follow-up action. <br /> "/CJs <br /> 2 . <br /> 3 . <br /> 4. <br /> 60 <br /> 5 . <br /> 8 . <br /> 9 . <br /> 100 _ <br /> - 11 . <br /> 12 . <br /> IV$ CERTIFICATION BY DESIGNATED 11 UST OPERATOR CONDUCTING THIS INSPECTION I <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 SignatureNEI <br /> j�fy <br /> V . OWNER 1 OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issues listed in Section /it above must have a description of the follow-up action taken or to be taken to correct the issue on the number <br /> line that corres o s ith the number line of the compliance issue listed above in Section 111. <br /> 1 . <br /> � J / <br /> 2 . <br /> 3 . <br /> 4. _ <br /> 5. --- <br /> 6. <br /> 7 . <br /> 8. <br /> 90 <br /> -- - — ._ <br /> 10 . <br /> 11 . <br /> 12 . <br /> VI . OWNER / OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> I 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 . Date Si ned <br /> Name o�_UST Owner/Operator (Print) UST Owner/Operator Signature 9 <br /> CERS = California`EmAronmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />