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CERS = California Environmental RenartinA System, ID = Identification, UST = Undernround storarae tank. [CC= Intern <br />UNDERGROUND STORAGE TANK <br />DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT Pa e'1 of 2 <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Designated UST Operator Inspection <br />10132636 <br />2-23-2020 <br />Business Name (Same as facility Name or DBA -Doing Business As.) <br />FLYERS 487 <br />Business Site Address <br />City <br />ZIP Code <br />983 MOFFAT BLVD <br />IMANTECA <br />195336 <br />Il. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator (Print as shown on the ICC Certification.) <br />Phone ft <br />Clent Gagnier <br />(530) 521 6818 Ext. <br />ICC Certification #1 <br />5243792 <br />ICC Certification Expiration Date <br />9-11-2020 <br />III. COMPLIANCE ISSUES <br />Ali answerof "N' or NA" In sections Vll through XI must be explained in this section and may require follow-up action. <br />1. V111- NO SUMP OR LEAK ALARMS MARKED AS N/A <br />2. <br />3. IX- SMALL AMOUNT OF LIQUID IN ALL SPILL BUCKETS- REMOVED TO HAZ DRUM= ISSUE CLEARED <br />4. <br />5, <br />6, X- NOT REQUIRED- MARKED AS N/A <br />7. <br />8. NO COMPLIANCE ISSUES <br />9. <br />10. <br />19, <br />12. <br />IV. CERTIFICATION 13Y 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 t OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br />All issue 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 fine that <br />corresponds with the numberline the compliance Issue Is listed above In section 111. <br />2. Mere <br />3, <br />4. <br />s. <br />6. <br />7. <br />8. <br />9, <br />103 <br />11. <br />12. <br />Vi. OWNER / OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br />I have reviewed section 111 "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 UST Owner/Operator (Print) <br />UST Owner/Operator Signature <br />Date Signed <br />Os <br />_ <br />�la4�f <br />ational Code Council <br />