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!;NDEKGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br /> I. FACILITY INFORMATION <br /> CERS ID Date 9. 97,e UST Operator Inspection <br /> IN 6�tS <br /> Business Name(same as Facility Name or DBA-Doing Business As) <br /> 76- March Lane <br /> Business Site Address City ZIP Code <br /> 1916 March Lane Stockton 195210 - <br /> 11. <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST O rator int as show on the ICC Certification.) Phone# <br /> ICC Certification# ICC Certification Expiration Date <br /> Ill. COMPLIANCE ISSUES <br /> All answers of"N"or"NA"in s ctions VII through XI must be explained in this section and ay require follow-up action. <br /> 2. — - <br /> s. DEC 1 2020—---- <br /> 7. <br /> 8. "JVIRn"'MENTAL HEALTH <br /> . - -- -- JICES <br /> 9. PFRMITISEP. —_ <br /> 10. <br /> 12. - <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> 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///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 correspon . ith the number line of the compliance issue listed above in Section Ill. <br /> 2. <br /> _ --- <br /> 3. <br /> .4 — -- <br /> _ _ ------ -- <br /> 7. — <br /> .............. <br /> 8. - -- <br /> 9 <br /> 10. <br /> 12. <br /> VI. OWNER 1 OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> 1 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 Signed <br /> Name of UST Owner/Operator(Print) UST OwneriOperator Signature <br /> CERS=Cafrtomia 1 nmAronmeriral Reporting System,lD=tdentitr,as x� USI=Undarground Storage Tank,ICC=Intemational Code Council <br />