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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 /> 10l gods 3S <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> EL Acjr42�- <br /> Business Site Address CityZIP Code <br /> 9 'ZO � <br /> II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification.) Phone # <br /> Iz LL 1<4 C9 ?(0 ) &7d - S93Z <br /> ICC Certification # ICC Certification Expiration Date <br /> Ute- <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 /> 1 a <br /> 6 � � G2F► Il �RE� T, orl 7;�STyn�G rcldog5 31 , /o -y3— / Y <br /> 2 • /U /4 TAT ASIA Gine Ti6A(7W44CSS T)eS7 /44Wiv 4 ��6 � uts2 fl f `S &W-M <br /> 3 . <br /> - -4. - <br /> 5. <br /> 60 <br /> - -- - <br /> 7 . <br /> 8 . <br /> 9 . <br /> - --- <br /> 10 . <br /> 11 . <br /> J 12 . - <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> 1 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 KOPERATOWbESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issues listed in Section ill 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 /> 2 . <br /> 30 <br /> 4. - <br /> 5. _ <br /> 6 . <br /> 7 . <br /> 8. - - --- - - - - -- <br /> 9 . <br /> 10 . <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 Ow r/Operator Signature Date Signed <br /> 2 5 -- <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council <br /> UN -111 www. unidocs.org 1 /2 - Rev. 06/14/18 <br />