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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Page t of 2) <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10166191 09/04/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> 7-Eleven 35355 <br /> Business Site Address City ZtP Code <br /> 3202 W. Hammer 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 7129/2021 <br /> III. COMPLIANCE ISSUES <br /> All answers o1"Al"or­NA­in sections VIl through Xl must be explained in this section and may require tollow-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 2716 and all the 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 Ill 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 line 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 111"COMPLI CE ISSUES" d provided a description in Section V of the action taken or to be taken <br /> to correct the 0jues discovered. <br /> Name of UST erlOperator(Print) UST OwnerlOper0 Signature Date§ignecy <br /> CERS=Ca Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />