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UNDERGROUND STORAGE TANK <br /> FDESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br /> 1 . FACILITY INFORMATION <br /> 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 I Stockton 195206 <br /> I1 . ' DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification.) Phone # <br /> Randall Kirby (916) 870-5932 <br /> ICC Certification # ICC Certification Expiration Date <br /> 5250566- UC 10/23/2019 <br /> Ill . COMPLIANCE ISSUES <br /> All answers of `N" or "NA " in sections VIl through Xl 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 /> 2s /i U_ OeIL /dAI77AA/ 7ZSTi�/(, <br /> 3 . C_u <br /> 4. <br /> 6. . --- <br /> _ 7 '__ <br /> 8 . <br /> 9 . <br /> ion <br /> 11 . <br /> 12 . <br /> i <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> j 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/ OPERA OR 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. 0 AJO I .E <br /> F <br /> - 2 . T.�S N "LiJ .5 C lleXb IJ <br /> 30 <br /> 4. <br /> 5. <br /> 6. <br /> 79 <br /> . <br /> 8 <br /> _ __ - . <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 /> N e of UST Owrt drperator (Print) UST Owner/Operator Signature Date Signed <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br /> UN411 www.unidocs.org 112 - Rev. 06/14/18 <br />