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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 IDe of Dnated UST Operator Inspection <br /> 10180839 = esig& - w= / <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> EI Dorado Food Mart 510 - 557-4508c - montereyfuelinc@yahoo . com <br /> Business Site Address City ZIP Code <br /> 1901 S . EI Dorado Ave I Stockton 195206 <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 /> III . COMPLIANCE ISSUES <br /> All answers of "N" or 'NA " in sections Vl/ 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 . fit/ �. �r goL .s. 7- , 6' -3— ig s - a � - � 9 . St23� jrZ <br /> 3. �� Cp.V�zq�it/ �'L ui� _ <br /> 4. . pt�LsRFi1L �QvPT_/_N_U_b % 74_6 01¢�� -- <br /> - - - - -- <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> low <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 and all the info mation provided herein is accurate. <br /> Designated UST Operator Signature <br /> V. OWNE / OPE R 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 Ill. <br /> 1 . 0 !4—nlfz-- — ----- ----- --- — -- <br /> 2 . <br /> 3. <br /> 4. S <br /> 5. <br /> 62 <br /> 7 . <br /> 80 <br /> 9 . <br /> 10 . <br /> 11 . z <br /> 120 <br /> VI . OWNER / OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> I have reviewed Section 111 "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) USJT Owner/Operator Signature____— Date Signed <br /> CERS = California Environmental Reporting SKem ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> UNA11 www.unidocs .org 112 - Rev. 06/14/18 <br /> 4 - <br />