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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Page•I of 2) <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10166191 08/1112020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> 002W. <br /> 5355 <br /> e Address City ZIP Code <br /> ammer Lane Stockton 95209 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) Phone# <br /> Kevin Dutra (949)460-5200 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9273805 7/29/2021 <br /> III. 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 /> 1. Site has double-walled lines. <br /> 2. Site has double-walled tanks. <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 2719and all the 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 M 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 lime of the compliance issue listed above in Section 111. <br /> 1.No follow-up required. <br /> 2. No follow-up required. <br /> VI. OWNER 1 OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <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 Owner/Operator(Print) UST Owner/ perator Signature Dateig ed <br /> �{ Z� U <br /> CERS=Californ' Environmental Reporting System,ID=idendcation,UST=Underground Storage Tank,ICC=International Code Council <br />