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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10156819 1/7/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> SAFEWAY#2707 <br /> Business Site Address City �95 <br /> 6425 N. Pacific Ave Stockton <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) Ph 9 e# 2I /(p� <br /> Rita Martinez `�' `� 7 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9028811 1/25/21 <br /> III. COMPLIANCE ISSUES <br /> All answers of"N"or"NA"in sections Vll through XI must be explained in this section and may require follow-up action. <br /> 1, TLS CURRENTLY ALL FUNCTION.S NORMAL .............._-._ _ __.____ ............. <br /> ._....... --.._ <br /> 2. T 1 REGULAR OVERFILLALARM 01/0320 SELF CLEARED _. ...... ... ........._-. ..................... <br /> _---.._ ............... .. ..........--._ . ...... ....... .............---.._.—.._..... <br /> _ <br /> 3. PROBE OUT 01/03/20 SSS JOB 346445 — — <br /> _-. <br /> ................... _.........-.... <br /> .._----- - - -.. - <br /> 4. T 2 PREMIUMOVERFILLALARM 01/03/20 SELF CLEARED ._ __.--- _ ...... ...... <br /> _ <br /> ----. ................ _..... ............__ <br /> 5. PROBE OUT 01/03/20 SSS JOB 346445 _......- ------------_111 .... ................_ <br /> _ ... <br /> __-__ _ .._....__—--- - — -. <br /> 6. T3 OVERFILL ALARM 01/03/20 SELF CLEARED .............. . <br /> ...... ... <br /> _. <br /> ............. ........_...... .... _—.- — — <br /> 7. PROBE OUT 01/03/20 SSS JOB 346445 . ............. __ ....I...... <br /> 8. .............. -._............ ..... .................... -. ......... ...... <br /> 9. __ .......................................................................-_.._._.........-..._ <br /> 10. ...... ........_........ <br /> 11. TANK/LINE TIGHTNESS TESTING NOT REQUIRED .................._ _. . ....... __ -...... <br /> 12. PLEASE PROVIDE COPY OF SECONDARY CONTAINMENT <br /> IV. CERTIFICATION BY 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 information provided herein is accurate. <br /> Designated UST Operator Signature 'WA <br /> V. OWNER/OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issues listed in Section 111 above must have a description of the follow-up action taken or to be taken to correct the issue on the number <br /> line that corresponds with the number line of the compliance issue listed above in Section 111. <br /> 1. ..................-----........................----- ---.............................................. <br /> . <br /> --_-1.11,111 1111111111, <br /> 2. - -----.-.............................................. <br /> 3. ............_....----- - — _.__,........r::................................. <br /> 4. __.....__......_._............................ ......... <br /> 5 . <br /> 6 _____.--........__._........._........_..._.._.._........................_._......... <br /> 7. ....... ---.............. ............ _....._.....-._.......__.._._................ <br /> ._........ <br /> 8. <br /> 9. <br /> 10. ..................................................................._....._._...w.-...._.._... <br /> 11. .....- . -...__. .... _ ........ .......... <br /> 12. -- ,\o r4, c cam✓ cJ u^ <br /> VL OWNER/OPERATOR ACKNOWLEDGMENT OF COM16LIANCE 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 U$T Owner/Operator rPrint% �\wnerto natur�eh, Date SSgned - <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />