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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 Desi9rated UST Operator Inspection <br /> (7 ✓-h- <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 /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Desi 1ST for Print as shown on the ICC Certification.) Phone# <br /> ICC Certification:: / !CC Certification E iration Date <br /> III. COMPLIANCE ISSUES <br /> All answers of"Al"or"NA"in sections Vll through XI t be explained in this section and may require follow-up action. <br /> _ J `7 <br /> 3. <br /> -- _ - <br /> 4. <br /> 6. <br /> -- ----- - — NTA I.. <br /> -7'— ----- --- -. ; <br /> 9. <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, Title 23, <br /> Division 3,Chapter 16, Section 2716 and all a information provided herein is accurate. <br /> Designated UST Operator Signature ��.. <br /> V. OWNER 1 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 betaken to correct the issue on the number <br /> line that co res rtgs yvifh the number line of the compliance issue listed above in Section I!!. <br /> 2. - --- <br /> 3 - - - - -- <br /> 4. <br /> 6. <br /> 7. - -- <br /> 8. — --- — <br /> _....10. <br /> 12. -- - <br /> VI. OWNER f 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 /> Name of UST Own er/Operator(Print) 1 UST Owner/Operator Signature Dste Signed <br /> CERS=California Enw ,-nmental Reporting System;ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Counal <br />