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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Page I of 2) <br /> CERS ID FACILITY INFORMATION <br /> ........... Date of C3esignated UST Operator inspection <br /> 10594654 1 <br /> Business Name(Sarre as <br /> Facility Name or DBA-Doing Business As) <br /> Pacific Avenue Chevron <br /> Business Site Address City ZIP Code <br /> 6633 Pacific Avenue IStockton 195207 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) <br /> Phone 4 <br /> Michael Reimers Stephanie Murphy (209-380-5542) (916) 967-2279 <br /> ICC Certification# 160 Certification Expiration Date <br /> 8/20/2020 <br /> Ill. COMPLIANCE ISSUES <br /> All answers of"N"or"NA"in sections V11 through X1 must be explained in this section and may require follow-up action. <br /> .............. ....... ......Uyl-k-15E.L.-amult <br /> 2. .. ..............................- <br /> 3. ............................... ............... ....... <br /> ............... . <br /> . ..... . <br /> ............................... <br /> 4. <br /> 5. <br /> 6. <br /> 7. .......... - <br /> 8. ­................................. <br /> 9. .. ................................ — <br /> ....... ------ .......... <br /> .......................-................................. ....- .. ............................ ..................................... ................ <br /> 10. <br /> 12. <br /> N. WWT CATIDESIGNATED UST O0dRATOR CONDUCTING THIS INSPECTION <br /> --............................ <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 infoion t* provided herein is accurate. <br /> ,xm# <br /> Designated UST Operator Signature <br /> .........................___.......- <br /> V. <br /> .............. .......-V. '1,219!@!�§—PERATOR SC PTION OF FOLLOW-UP ACTIONS <br /> All issues listed in Section///above must have a description of th-4*4kyk-up action taken or to be taken to correct the issue on the number <br /> fine that corresponds with the number line of the compliance issue listed above in Section //l, <br /> 2. <br /> 3. <br /> ......... <br /> 4. ............. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> .......... <br /> 10. <br /> 12. <br /> .................... V1. OWNER!OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> ............. <br /> I 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 OwnerlOperator Tdyt) UST Owner/Operator Signature bai*--Signed <br /> CERS=Calftnia ErNronmental Reporting System,ID=Iderftation,UST=Underground Storage Tank,[CC In *nal Code coundl <br />