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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (page 1 of3) <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10184349 D GTO f3EK— L-5 L <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> PILOT / FLYING J TRAVEL PLAZA #617 - LODI <br /> 15237 THORNTON RD. City ZIP TLODI 95242 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC Certification.) Phone# <br /> LANCE YORK (949) 230-8931 <br /> ICC Certification# ICC Certification Expiration Date <br /> 5296385-UC AUGUST 1, 2020 <br /> III. COMPLIANCE ISSUES <br /> All answer of`N"or"NA"in sections VII through XI must be explained in this section and may require follow-up action. <br /> 1. OVG(2-PLL. Ga%-LkprvAC), 1J4.PCGTI0►-� MC-C—:De-0 <br /> 2. f P �rtcv�� CC%�CD <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> 11. <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 anA all the information provided herein is accurate. <br /> Designated UST Operator Signature <br /> /�"4/1- <br /> V. OMEKI PERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issue listed in section 111 above,must hay a escription of the follow-up action taken, or to be taken,to correct the issue on the number line that <br /> corresponds with the number line the compliance issue is listed above in section III. <br /> (NSPEGTIOAJ Is SCNCovLc-D <br /> 2. W 5C+k(?,0 U(.E EtA�W Ee-s- r--9— -tz-Al d r J UCKT V.0. /JS PEzT7 v <br /> 3. <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> 11. <br /> 12. <br /> VI. OWNER I 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 UST Owner/Operator(Print) UST Owner/Operator Sin ure Date Signed <br /> -p(LnT EL1 ��r-- <br /> CERS-California Ernirorrnenial Reoortina System ID=Identification.UST-Underground storage tank ICC-InWrrudonal Code Council <br />