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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 /> 10180839 _ _ <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> EI Dorado Food Mart 510 - 5574508c - montereyfuelinc@yahoo . com <br /> Business Site Address City ZIP Code <br /> 1901 S . EI Dorado Ave - Stockton 195206 <br /> lie DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the /CC Certification.) Phone # <br /> Randall Kirby ( 916) 870 -5932 <br /> ICC Certification ## ICC Certification Expiration Date <br /> 5250566- UC 10/23/2019 <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 /> --tor ►ALL- 011: — A % - <br /> 2 ' n1 'K AJIJ6 UNf�r16H iJC45 fw'rr2 ulazb . ut)e. <br /> 3 . <br /> 4 . <br /> _ _ _ - - ---- - -- - - -- - ------ -- - - -- - - ----- <br /> 66 <br /> -- - ---6 . <br /> 70 <br /> 8 . — -- — — <br /> 98 <br /> 10 . <br /> 11 . <br /> 12 . <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> 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. OWNE l PERATO§ DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issues listed in Section 1/1 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 IN. <br /> 1 . 7,C577A/6 <br /> 2 . Naves <br /> 3 . <br /> 40 <br /> 5. _ — -- — --- — -- — — ----- - - - <br /> 6 . <br /> 7 . <br /> 8 . <br /> 96 <br /> 10 . -- — — -- -- -- — ------ -- -- <br /> 11 . s <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 Owne perator Signature Date Si ned <br /> CERS = Caffomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> UNA11 www. unidocs .org 1 /2 - Rev. 06/14/18 <br />