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1515 E. Main St, Stockton, CA 95205 PR0545645 <br /> 10/22/2021 Program: UST <br /> PHOTO 1: <br /> The 01/07/2021 monthly inspection report was si ned/dated b the owner/operator on 01/06/2021, before the inspection date. <br /> Underground Storage Tank <br /> Appendix XIII Designated UST Operator Visual Inspection Report <br /> Underground storage Tank <br /> Designated UST Operator Visual Inspection Report OPERATOR DESCRIPTION OF FOLLOW-UP ACTION <br /> e follow up actions to correspond to appropriate compliance issues from Section <br /> 1. FACILITY INFORMATION <br /> CERS ID 10651991 Inspection Date o1/o7/2021 <br /> Facility Name 7-Eleven 38877 <br /> City ZIP Code <br /> Facility Address Stockton 5205 <br /> 1515 East Main Street <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Name of Designated UST Operator Phone <br /> Kevin Dutra (949)460-5200 <br /> ICC Certification Certification Expiration Date <br /> 9273805 7129/2021 <br /> 3. COMPLIANCE ISSUES <br /> f <br /> 6. NER/OPERATOR ACKNOWLEDGEMENT OF INSPECTION RESULTS <br /> I have reviewed the results of the designated UST operator inspection report and provided a <br /> description of the action(s)taken or to be taken to correct any compliance issues discovered. <br /> Name of UST Owner/Operator(print) R p <br /> � Q N kJ C..�� GP <br /> UST Owner/Operator Signature Date Signed <br /> l A 12-1 <br /> 7. INSPECTION HISTORY <br /> Has each follow-up action of Section 3 from the previous Designated UST Yes No NA <br /> Operator Inspection Report been completed appropriately? <br /> Attach documentation verifying appropriate service to this report.) 0 ❑ ❑ <br /> 8. RELEASE DETECTION ALARM HISTORY <br /> Attach a copy of the alarm history report/log to this report. Yes No NA <br /> 4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION Is the monitoring system powered on and in proper operating mode? H ❑ <br /> I hereby certify that the visual inspection was performed in compliance with California Code Has each alarm since the previous inspection been responded to appropriately? <br /> of Regulations,title 23,division 3,chapter 16,section 2716 and all information provided A (Attach documentation verifying appropriate service to this report.) E3 [I I1 7 <br /> herein is accurate. Have all containment sumps,that have had an alarm since the previous <br /> designated UST operator inspection report,been responded to by a qualified <br /> Designated UST Operator Signature Date Inspection Report Provided to Owner service technician? ❑ ❑ [�( <br /> 'C 91197/2921 <br /> GERS=California Environmental Reporting System,ICC=International Code Council,ID= All answers marked"No"must be described by the designated UST operator in Section 3. B <br /> Identification,Tank ti NA=Not Applicable,UDC=Under-Dispenser Containment,UST=Underground <br /> storagePage 2 of 4 <br /> 7-11-38877-01/07/2021 <br /> Page 1 of 4 <br /> VICKY VANG-LEE, EHS Page 1 of 2 <br />