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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10146151 04/23/2020 <br /> Business Name(Same as Facility Name or CBA-Doing Business As) <br /> Costco Wholesale -LODI -1091 <br /> Business Site Address City ZIP Code <br /> 2680 Reynolds Ranch Pkwy Lodi 95240 <br /> IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the)CC Certification.) Phone# <br /> Michael Moore (949)460-5200 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9495322 12/17/2021 <br /> Ill. COMPLIANCE ISSUES <br /> All answers of N"or NA"in sections V11 through XI must be explained in this section and may require follow-up action. <br /> 1. Site is continuously monitored. <br /> 2. Site has double-walled tanks. <br /> 3. Site has double-walled lines. <br /> N. CERTIFICATION BY DESIGNATED U O T R CONDUCTING THIS INSPECTION <br /> I hereby certify that the visual inspection was perfo d ' ful o nc ith California Code of Regulations, Title 23, <br /> Division 3,Chapter 16,Section 2716 and all the inform io prov- h ein ' c te. <br /> Designated UST Operator Signature <br /> V. OWNER 1 OPERATOR DESCRI I 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 corresponds with the number fine of the compliance issue listed above in Section 111. <br /> 1. No follow-up required. <br /> 2. No follow-up required. <br /> 3. No follow-up required. <br /> VI. OWNER 1 OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> I have reviewed Section III"COMPLIANCE ISSUES" and provided a description in Section V of the actidir taken oro be taken <br /> to correct the issues discovered. <br /> Name of UST Owner/Operator(Print) U 10 rat Si ature at s gr O <br /> Shelli Deppman <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />