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jAppendix Xlil <br /> Underground Storage Tank <br /> Designat UST Operator Visual Inspection Report <br /> r 1. FA ILITY INFURNIATI <br /> I <br /> CERS ID 10181411 i Inspection Date 11/25/20 <br /> Facility Name Tracy Blvd Shell 2 �ni Mart <br /> Facility Address I� City hP Code <br /> 3725 N Tr cy Blvd ! Tracy 9 376 <br /> 2. DE IGN'ATED UST 00 �T:qh INFt R;MATION <br /> Name of Designated UST Op rator Phone <br /> Richard Schmidt <br /> (408)971!2445 <br /> ICC Certification Certification Expiration D ate <br /> 9023055 01/10/21 <br /> 3. '00 P'LIANCE ISSUES; . <br /> i <br /> Identity by number all compli !ra issues listed <br /> Monitor in Alarm at Time of Inspection <br /> 13: External Input Alarm-SSS#38366d'141 <br /> 14: External Input Alarm-SSS#38N6,1 <br /> T1:IR gular 87-High Water Alam SSS#38546 <br /> T1:IR gular 87-Overfill Alarm.: SSS#38546' <br /> Ti:;R gular 87-Probe Out Alarm. SSS#38546"; <br /> T2: Rgalar 87 Aux. High Bate rm. ;SSS#M467 <br /> T2: R igular 87 Aux.-Probe Out All rm. SSS#38..467 <br /> T2: R gular 87 Aux.-Invalid Fuel! evel.i SSS#38 467 <br /> T2:R gular 87 Aux.-Low Temp ii'I.:rm. 'SSS#38 467 <br /> 02:'Plus-PLLD Shutdown Atari I SSS#385461 <br /> Tank/l.ine Tightness Testing Nol 1 quired <br /> Diesel Fill Bucket Has Liquid <br /> Dispenser 15/16 UDC Has Liqui <br /> Rupin er Allan and Mohammad shal Naim are Overdue for Training <br /> 4. CI <br /> ETIFICATION BY D = 1 GNATED U`$T OPERATOR CONDUCTING INSPECT! N <br /> he y certify that the vi ! ' I inspecti n was performed in compliance with Cali ornia Code <br /> of Rig lations, title 23, di � ion 3, cha' ter 16, section 2716 and all information.. p iovided <br /> her is accurate. <br /> Design ted UST Op tato atuCe Date Inspection Report Provi ed to Owner <br /> L� <br /> 11/2512020 : <br /> CERS California Environ 1 tal Reporting System, ICC = International Code Council ID = <br /> Identification, NA = Not.App i ble UDC iUnder-Dispenser Containment, UST = Underground <br /> Storage Tank <br /> Page I of 4 <br />