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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (page 1 of 2) <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 110156057 06- 12-2019 <br /> Business Name (Same as Facility Name or DBxDoing Business As.) <br /> U . P . S . <br /> Business Site Address City ZIP Code <br /> 1532 Broadway Stockton 95205 <br /> IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the /CC Certification.) Phone # <br /> David Pereira (510) 889 - 0908 Ext. <br /> ICC Certification # ICC Certification Expiration Date <br /> 5240739- UC 04-25-2020 <br /> III . COMPLIANCE ISSUES <br /> All answer of °N" or "NA " in sections Vil through XI must be explained in this section and may mqulre follow-up action. <br /> 1no tank tightness test needed <br /> 2. no line tighness test needed <br /> 3. All sensors set off 5-20-2019 <br /> 4. <br /> 6. <br /> 6 . <br /> 7. <br /> 8 . <br /> 9 . <br /> 10 . <br /> 11 . <br /> 12. <br /> IV. CERTIFICATION SY 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 n qr ation provided herein is accurate. <br /> Designated UST Operator Signature <br /> V. OWNER / OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issue listed in section lit above, must have a description of the follow-up action taken, or to be taken, to correct the issue on the number line that <br /> corresponds with the number line the compliance issue is listed above in section ill. <br /> 1 . due to having double wall tank with anular space <br /> 2. due to double wall piping installed <br /> 3. All sensors set off 5-20-2019 due to annual monitor certification <br /> i <br /> 4. <br /> i <br /> 5. <br /> i <br /> 6. <br /> 7 . <br /> 8 . <br /> 9 . <br /> 10. <br /> 11 . <br /> 12. <br /> VI. OWNER 10PERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> I have reviewed section III "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/Operator Signature Date Signed <br /> Maurice Barksdale <br /> CERS = CalifonvaEnvironn*ntWReaortinnSystem. ID = Identi@catlon. LIST = Underarourxi tanit. JM = kftMl§gMCadeCourctl <br /> t <br />