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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 pate of Designatrc! 1133TT OperatorInspection <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 95210 <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Desi ST for Print as shown on the ICC Certification.) Phone# <br /> ICC Certification# ICC Certification Fpiration Date <br /> --fid <br /> III. COMPLIANCE ISSUES <br /> All answPrs of W or'W in sections VIl through Xl—^ ct hp.exolained in this section and may require, follow-up action. <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 7- ENVIRONMENTAL HEALTH <br /> 10. <br /> 12. <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, Title23, <br /> Division 3,Chapter 16,Section 2716 and al!_W 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 111 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 cojres�SrrjJs ith the number line of the compliance issue listed above in Section/H.1. i�L,/1" <br /> 2. <br /> 3. <br /> 4. <br /> 5 <br /> '6. <br /> 7. <br /> 8. <br /> 10. <br /> 12. <br /> VI. OWNER/OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> 1 have reviewed Section Ill"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(Pont) UST Owner/Operator Signature Date Signed <br /> c <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank ICC=International Code Coural <br />