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Appendix XIII <br /> UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2 <br /> Noon <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 01w.5 7 10/05/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> 7-Eleven 14113 <br /> Business Site Addres Citv Zip Code <br /> 3040 West Benjamin Holt Drive Stockton 95219 <br /> II , DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification ) Phone Number <br /> Mark Rasmussen (949) 460-5200 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8867893 12/27/2019 <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 . Initial monitoring certification completed on 9/20/18 has failing components . <br /> 2. Liquid present in both 87 spill buckets . <br /> 3. Liquid present in both 91 spill buckets . <br /> 4. Site has double-walled lines . <br /> 5. Site is continuously monitored . <br /> 6. Site has double-walled tanks . <br /> 7, Overfill Prevention Equipment Inspection is not on site. <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 /> 1 . Retest scheduled . <br /> 2 . Dispatched certified technician, confirmation #56995029 <br /> 3, Dispatched certified technician, confirmation #56995029 <br /> 4. No follow-up required . <br /> 5. No follow-up required. <br /> 6. No follow-up required. <br /> 7 . Will provide completed inspection by 10/13/18, <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 <br /> le of UST Owner/O a ator Print UST Own NOperator Signature Date.Si ned <br /> is <br /> CERS = Cal iforniaEnvironmental Reoortina System, ID = IdLificabon , US — der round storage tank ICC = International Code Council <br />