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1515 E. Main St, Stockton, CA 95205 PR0545645 <br /> 10/22/2021 Program: UST <br /> PHOTO 2: <br /> The 02/03/2021 monthly inspection report was signed/dated by the owner/operator on "Jan (2)", before the inspection date. <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> Appendix XIII <br /> Underground Storage Tank 5. OWNERIOPERATOR DESCRIPTION OF FOLLOW-UP ACTION <br /> Designated UST Operator Visual Inspection Report Number the follow up actions to correspond to appropriate compliance issues from Section 3. <br /> 1. FACILITY INFORMATION <br /> CERS ID 10851091 Inspection Date o210312021 <br /> Facility Name 7-Eleven 38877 <br /> Facility Address <br /> 1515 East Main Street CITy Stockton ZIP Code <br /> 52 5 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Name of Designated UST Operator Phone <br /> Kevin Dutra <br /> (949)4605200 <br /> 19273805CC rtfication Certification Expiration Date <br /> 3. COMPLIANCE ISSUES 7/29/2021 <br /> i <br /> 6. OWNER/OPERATOR ACKNOWLEDGEMENT OF INSPECTION RESULTS <br /> 1 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) <br /> UST Owner/Operator Signature 11 Date Signed <br /> QW <br /> 7. INSPECTION HISTORY <br /> C <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 /> 4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION Attach documentation verif in a ro riate service to this re ort. ❑ ❑ Q <br /> I hereby certify that the visual inspection was performed in compliance with California Code <br /> S. RELEASE DETECTION ALARM HISTORY <br /> of Regulations,title 23,division 3,chapter 16,section 2716 and all information Provided 7 <br /> herein is accurate. Attach a copy of the alarm history reportgog to this report. Yes <br /> Designated UST Operator Signature Is the monitoring System powered on and in proper operating mode? NO NA <br /> Date Inspection Report Provided to Owner f Has each alarm since the previous inspection been responded to appropriately'? <br /> R1 ❑ <br /> ovo3/2oz1 <br /> (Attach documentation verifying appropriate service to this report.) [�( <br /> ,!CERS=California Environmental Reporting System,ICC=International Code Council,ID= <br /> Have all containment sumps,that have had an alarm since the previous <br /> ❑ ❑ <br /> Storage Tan,NA=Not Applicable,UDC=Under-Dispenser Containment,UST=Underground <br /> Storage Tank designated UST operator inspection report,been responded to by a qualified <br /> service technician? RI ❑ <br /> Page 1 of q <br /> All answers marked"No"must be described by the designated UST operator in Section 3. <br /> Page 2 of 4 <br /> VICKY VANG-LEE, EHS Page 2 of 2 <br />