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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 <br />10146151 <br />Date of Designated UST Operator Inspection <br />04/23/2020 <br />Business Name (Same as Facility Name or CBA -Doing Business As) <br />Costco Wholesale - LODI -1091 <br />Business Site Address <br />2680 Reynolds Ranch Pkwy <br />City <br />Lodi <br />ZIP Code <br />95240 <br />IL DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator (Print as shown on the )CC Certification.) <br />Michael Moore <br />Phone # <br />(949) 460-5200 <br />ICC Certification # <br />9495322 <br />ICC Certification Expiration Date <br />12/17/2021 <br />Ill. COMPLIANCE ISSUES <br />All answers of N" or NA " in sections V11 through XI must be explained in this section and may require follow-up action. <br />1. Site is continuously monitored. <br />2. Site has double -walled tanks. <br />3. Site has double -walled lines. <br />N. CERTIFICATION BY DESIGNATED U O T R CONDUCTING THIS INSPECTION <br />I hereby certify that the visual inspection was perfo d ' ful o nc ith California Code of Regulations, Title 23, <br />Division 3, Chapter 16, Section 2716 and all the inform io prov- h ein ' c te. <br />Designated UST Operator Signature <br />V. OWNER 1 OPERATOR DESCRI I 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 fine of the compliance issue listed above in Section 111. <br />1. No follow-up required. <br />2. No follow-up required. <br />3. No follow-up required. <br />VI. OWNER 1 OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br />I have reviewed Section III "COMPLIANCE ISSUES" and provided a description in Section V of the actidir <br />to correct the issues discovered. <br />taken oro <br />be taken <br />Name of UST Owner/Operator (Print)U <br />Shelli Deppman <br />10 rat 5i ature <br />at 5 <br />11iZ <br />O <br />I • 1 / <br />CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council V V <br />