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1 <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 /> 10182257 7/5/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> WINE COUNTRY 76 <br /> Business Site Address City ZIP Code <br /> 111 E KETTLEMAN LANE LODI 195240 <br /> Il.' DESIGNATED ' UNDERGROUND STORAGE TANK OPERATOR 'INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification.) Phone # <br /> Felix Ramirez (209) 744 -0112 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8883072- UC 3/ 1 /2020 <br /> 111 . 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 . TESTING DONE LAST MONTH <br /> 20 <br /> 3 . <br /> _ <br /> 5 . <br /> 6 . <br /> 7 . <br /> 8 . <br /> 94 <br /> 10. <br /> 11 . NO LINE TEST BECAUSE SITE HAS POSITIVE SHUTDOWN <br /> 12 . NO TANK TEST BECAUSE SITE HAS DOUBLE WALL TANKS <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 /> t <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/O erator (Pr' t) ( UST 0 r/Operator Signaye Date Signed <br /> WIN, <br /> CERS = Cafdomia EnVronmentai Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council <br />