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UE020 <br /> 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 /> 10207012 01 /21 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Pacific Bell Telephone Co. dba AT&T California <br /> Business Site Address City ZIP Code <br /> 124 W. Elm St. Lodi 95240 <br /> II . DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification.) Phone # <br /> George Koffel (714) 920-5387 <br /> ICC Certification # ICC Certification Expiration Date <br /> 5247982-UC 10/23/2020 <br /> III . COMPLIANCE ISSUES ❑ Check If Action Item(s) Are Present <br /> All answers of "N" or WX in sections V/l through XI must be explained in this section and may require follow-up action. <br /> 1 . Items on form marked NA and/or require no follow-up: <br /> 2 . Section VIII - There have been no leak detection alarms since last visit. <br /> 3 . Section IX - Facility has no dispensers . <br /> 4. Section X - Line and tank tightness testing not required . <br /> 5. Section X - Tait management has determined that monitor certification paperwork provides acceptable and compliant <br /> 6s documentation of audible/visual overfill prevention equipment inspection . <br /> 7. <br /> 8 . <br /> 9 . <br /> 10 . <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 information provided herein is accurate. <br /> Designated UST Operator Signature <br /> �G <br /> V. OWNER / OPERATOR 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 lll. <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4. <br /> 5. <br /> 6 . <br /> 7. <br /> 8 . <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 /> Name of UST Owner/Operator (Print) UST Owner/Operator Signature Date Signed <br /> CERS = California EnWonmental Reporting rti System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />