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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 12/3/20 <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 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 CURRENTLYALL FUNCTIONS NORMAL <br /> 2. NO NEW ALARMS TO REPORT THIS PERIOD <br /> . _.......-- --- .... . <br /> ... . ..._.... <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. PROVIDED TRAINING TO KARLA CARILLO <br /> 8. <br /> 9. PREVIOUS D.O. INSPECTION NOT SIGNED <br /> 10. PLEASE PROVIDE COPY OF SECONDARY CONTAINMENT********** <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/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 /> 5. <br /> 6. <br /> 7. <br /> 8. ....... _. . ... .... -- --- --—_ — ......- . .___. _....... ---- -- -- ................................... <br /> — - - -- - <br /> 10. <br /> zf� 0 - <br /> 12. <br /> VI. OWNER/OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> 1 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 /> Na'-'-of UST Owner/Operator(Print) US wner/Operat Si nature Date Signed <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council <br />