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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 /> 10181497 4/ 17/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> SRH - US GASOLINE <br /> Business Site Address City ZIP Code <br /> 749 E CHARTER WAY STOCKTON 95207 <br /> Il . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification.) Phone # <br /> Edward Stearns (209 ) 744-0112 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8883080 - UC 2/23/2020 <br /> III . COMPLIANCE ISSUES <br /> All answers of N" or "NA " in sections VII through XI must be explained in this section and may require follow-up action. <br /> 1 . <br /> 2 . <br /> -- 3 . <br /> 4. <br /> 5 . <br /> _7 . <br /> 8 . <br /> 9 . <br /> 10 . <br /> 11 , SECTION X SITE DOES NOT REQUIRE TANK AND LINE TESTING <br /> 12 , SECTION VII NO ALARMS TO REPORT <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 /> w <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 111. <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4. <br /> 5 . <br /> 6 . <br /> _ 7 <br /> 8 . <br /> 9 . <br /> 10 . <br /> 11 . <br /> 12 . <br /> VI . 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 UST Owner/Operator (Print) UST Owner/Operator Signature Date Signed <br /> CERS = Cafrfornia Environmental Reporting System, ID = Identfication, UST = Underground Storage Tank, ICC = International Code Council <br />