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UNDERGROUND STORAGE TANK' <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTIONREPORT(Page 1 of 2) <br /> f FACILITY INFORMATION ; <br /> -- CERS ID Date of Designated UST Operator Inspection <br /> 10156819 3/3/20 <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 __7Stockton 95207 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION' <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) T(408) <br /> hone# <br /> Rita Martinez 971-2445 <br /> ICC Certification# ICC Certification Expiration Date <br /> 9028811 1/25/21 <br /> Ill. 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. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. PLEASE PROVIDE COPY OF SECONDARY CONTAINMENT <br /> 10. PREVIOUS 2 D.O. INSPECTIONS NOT SIGNED ***** <br /> - -- -- --- ----- - <br /> 12. TANK/LINE TIGHTNESS TESTING NOT REQUIRED <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/OPERA'pTOR 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 ill. <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> �.---- <br /> _—.�� <br /> 12. m- <br /> VL OWNER/OPERATOR ACKNOWLEDGMENT OF COMPLIANCE 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 I IRT Owner/Operator(Print) UST�Owner/Opera or ignature Date Signed <br /> J Y , <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />