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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1of 2) <br /> L FACILITY INFORMATION <br /> "TII CERS ID Date of Designated UST Operator Inspection Fh' <br /> F 10156819 3/31/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Safeway 2707 <br /> Business Site Address City ZIP Code <br /> 6425 N Pacific Ave Stockton 95207 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) Phone# <br /> Rita Martinez (408)971-2445 <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 FUNCTIONS NORMAL <br /> 2. NO NEW ALARMS TO REPORT THIS PERIOD <br /> 3. <br /> 4. <br /> 6. NEED TO REMOVE LIQUID FROM PREMIUM SPILL BUCKET <br /> 7. NEED TO REMOVE LIQUID FROM DISPENSER 7/8 <br /> 8. PREVIOUS D.O. INSPECTION NOT SIGNED <br /> 9. SITE NEEDS TO PROVIDE COPY OF SECONDARY CONTAINMENT TESTING <br /> 10. _ <br /> -- _ --- <br /> 11. TANK/LINE TIGHTNESS TESTING NOT REQUIRED <br /> 12. <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 <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 lll. <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> . <br /> 7 <br /> -_- <br /> _. 7.. <br /> 10. _ <br /> 12. <br /> VI. OWNER;/OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES' <br /> I 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 /> NamA of UST Owner/Oparator(Print) UST O Tr/Operator Sig u Date Signed <br /> Cr SC -2, <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />