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3725 N Tracy Blvd, Tracy, CA PR0231417 <br /> 01/20/2022 Program: UST <br /> PHOTO 7: <br /> The 09/02/2021 desi nated operator monthly inspection report was not signed by the owner/operator within 72 hrs <br /> Underground Storage Tank Ort <br /> + Designated UST operator visual Inspection Rep <br /> Appendix XIII <br /> Storage Tank -- 5. OWNERIOPERATOR DESCRIPTION OF FOLLOW-UP ACTON <br /> Underground StNumber the follow up actions to correspond to appropriate compliance issues from Section 3. <br /> Designated UST Operator Visual Inspection Report <br /> sroltgc <br /> IINO "1 1. FACILITY INFORMATION , <br /> 'ICEI NFORN !CERS ID <br /> 10161411 Inspection Date M3212_ <br /> Facility Name Tracy Brod shoo Mlnl Men <br /> 1GE Tq Facility Address City <br /> 3725 NTrecy Blvtl T,eCy ZIP Code <br /> 5s ICC C� 95376 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> c:nin Name of Designated UST Operator Phone <br /> Rlte Mertln4z (466)971-2445 <br /> TF—OF ICC Certification <br /> 9016611 Certification Expiration Data <br /> .her 12/15122 <br /> i'y. 3. COMPLIANCE ISSUES <br /> /denriry by number al/compliance issues listed <br /> TLS CURRENTLYALL FUNCTIONS NORMAL <br /> PROVIDED TRAINING TO MARIAN SOYKINS _ <br /> L 2 REGULAR AUX STP STP SUMP FUEL ALARM CTION RESULTS <br /> o6nonl:sss roe 4z4sso �. OWNER I OPERATOR ACKNOW LEDGEMENT OF INSPE <br /> d provided a <br /> 01 REGULAR PLLDSHUTDOWN ALARM � dhavescription of the actions)taken or to e reviewed the results of the designated UST operator inspection report an <br /> OaryDn1:SSS doe 424660 RRF���/// be taken to correct any compliance issues discovered. <br /> O <br /> Name of UST Owner/Operator(print) <br /> PLUS PLLD SHUTDOWN ALARM S <br /> Daii2D21 <br /> .SSS <br /> JOB 424660 Date Signed <br /> p <br /> 1)NEED TO REMOVE LIQUID AND DEBUST Owner/ rater SignaturflIS FROM PREMIUM AND DIESEL SPILL BUCKETS'•• <br /> 7. INSPECT ON 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 re rt. <br /> 8. RELEASE DETECTION ALARM HISTORY <br /> Attach a copy of the alarm history report/log to this report. Yes No NA <br /> Is the monitoring system powered on and in proper operating mode? © ❑ <br /> CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION Has each alarm since the previous inspection been responded to appropriately? ® ❑ ❑ <br /> ereby certify that the visual inspection was performed in compliance with California Code (Attach documentation verifying appropriate service to this report.) <br /> 'Regulations,title 23,division 3,chapter 16,section 2716 and all information provided Have all containment sumps,that have had an alarm since the previous <br /> Din is accurate. designated UST operator inspection report,been responded to by a qualified © ❑ ❑ <br /> ice technician? <br /> gnated UST ratorature Date Inspection Report Provided to Owner <br /> 09/0212021 r All answers marked"No"must be described by the designated UST operator in Section 3. <br /> =California Environmental Reporting System,ICC=International Code Council,ID'= <br /> cation,NA=Not Applicable,UDC=Under-Dispenser Containment,UST=Underground I Pape 2 of <br /> Tank <br /> i� <br /> Page 1 of 4 - --. <br /> VICKY VANG-LEE, REHS Page 7 of 7 <br />