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,4, ?n �> <br /> UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Pae 1 of 2) <br /> 1. FACILITY INFORMATION <br /> CERS ID of Desi hated UST Operator inspection <br /> 77� <br /> 10594654 ! _5 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Pacific Avenue Chevron _ <br /> Business Site Address City ZIP Code <br /> 6633 Pacific Avenue Stockton 195207 <br /> 11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the!CC Certification.) Phone# <br /> Stephanie Murphy _ _ _ (209) 380-5542 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9383552 10/1/2021 <br /> I IM COMPLIANCE ISSUES <br /> All answers of°N"or"NA"in sections VJl through Xl must be explained in this section and may require follow-up action. <br /> _.. .............. <br /> _. <br /> 2. ice ._ .... -� . ""'`Z �._ C ... <br /> 3. <br /> 4. <br /> 6. <br /> 7. <br /> 8. <br /> F- __ <br /> 10. <br /> 1i. <br /> 12. <br /> E IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> I hereby certify that the visual inspection was perforrned in full compliance with California Code of Regulations, Title 23, <br /> Division 3,Chapter 16,Section 2715 and all the information provided herein is accurate. <br /> Designated UST Operator Signature <br /> r d � <br /> V. cWN4R f PERATOR DESCRIPTION OF LL - P ACTIONS <br /> All issues listed in Section!11 above muhave a description of the follow-up action taken or to be-taken to correct the issue on the number <br /> line that corresponds with the number line of the compliance issue listed above in Section Ill. <br /> 2 ............. <br /> 3 _ <br /> 4. ._ <br /> W._.......... <br /> .._ _. __._.._ <br /> . <br /> 7. _. <br /> 8. .. .. <br /> 9. <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. <br /> Naamg.ef-UST Owner/Opera r( rint) UST OwnertOperator Signature Dat Signed <br /> VA UA <br /> CERS=Catifotnia Enuironnierrtal Reporting SYS,ID=identification,UST=Underrgrowd Storage Tank,ICC=International Code Council <br />