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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND .STORAGE TANK OPERATOR VISUAL INSPECTION REPORT Pae 1 of 2 <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10181513 9/25/2020 <br /> Business Name (Same as Facittty Name or DBA-Doing Business As) <br /> VAN DE POL ENTERPRISES - RIPON C F N <br /> Business Site Address City ZIP Code <br /> 816 E . FRONTAGE ROAD RIPON 195366 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Certification.) Phone # <br /> Zane Nimmo (209 ) 744-0112 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8883064-UC 2/ 17/2022 <br /> Ill. 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 . NO ALARMS . <br /> 30 <br /> -- 4. <br /> 7. <br /> 99 <br /> 106 <br /> 11 . ... <br /> 12, TANKS AND LINES ARE DOUBLEWALL AND DO NOT REQUIRE TESTING <br /> IV. CERTIFiCATiO.N BY DESIGNATED UST OPERATOR CONDUC71NO 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 / OPERATOR. DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All issues listed In Section /it above must have a description of the follow-up action taken or to betaken 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 . <br /> 20 <br /> 36 <br /> 62 <br /> . .._. ... <br /> 8. <br /> lie <br /> 10. <br /> 12, f <br /> VI. OWNER / OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> 1 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 er/Operator (Print) UST OwnerlOp rator Signature Date igne <br /> 14h �/1 GAJ <br /> CERS = Caibmia En Aronmenti Reporting System, ID = Ider0catim, UST = Underground Stora Tank, ICC = kntamatlonal Code Card <br />