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UNDERGROUND STORAGE TANK <br /> FDESIGNA;TED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br /> L FACILITY INFORMATION <br /> S IDDate of Designated UST Operator Inspection180839 7 _ .- <br /> Business Name (Same as Facility Name or DBA- )oing Business As) <br /> EI Dorado Food Mart 510 -5574508c - montereyfuelinc@yahoo . com <br /> Business Site Address <br /> CityZIP Code <br /> 1901 S . EI Dorado Ave - Stockton 95206 <br /> ll . 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 /> 111. COMPLIANCE ISSUES <br /> All answers of N" or Win sections Vll through XI must be explained in this section and may require follow-up action. <br /> 1 . NA - Tank and Line Tightness test aren 't require, UDC's are unpopulated <br /> 2. Aj04fV0fZVAS 38 400V <br /> 4' <br /> g -- - — -- ------ <br /> 7. <br /> 8. <br /> 9 <br /> 10 . --- - -- - - ---- — - <br /> lie <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 and all the information provided herein is accurate. <br /> Designated UST Operator Signature <br /> V. OWNER/OPERAT9R DESCRIPTION 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 /ll. <br /> 0'/V/E <br /> 2. XV7.LL [.ch// 8#5 SC46C [ Lic A61L%) <br /> 3. L --- <br /> 4. TIF <br /> 5. <br /> 6. - - <br /> ---- ----------- <br /> 74 <br /> - -- <br /> 8. - — ------ -- - - - <br /> 9. <br /> 10 . <br /> 11 . z <br /> 126 <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 nerJO rator Signature Date Signed <br /> CERS = Califomia Environmental Reporting ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> UN411 www.unidocs.org 112 - Rev. 06/14/18 <br />