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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Pae 1 012) <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Designated UST Operator Inspection <br /> 10181513 8/27/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> VAN DE POL RIPON CFN <br /> Business Site Address City 21P Cade <br /> i <br /> 816 FRONTAGE RD RIPON 95366 <br /> il. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator (Print as shown on the ICC Cert cation.) Phone # <br /> Felix Ramirez 209 744-0112 <br /> ICC Certification # ICC Certification Expiration Date <br /> 8883072-UC 3/ 1 /2022 <br /> Ili. COMPLIANCE ISSUES <br /> All answers of "N" or "NA " In sections Vil through XI must be explained in this section and may require follow-up action. <br /> 1 . NO LINE TEST BECAUSE FAIL SAFE <br /> 2. NO TANK TEST BECAUSE OF DOUBLE WALL TANKS <br /> 36 <br /> 4.. .. <br /> 6. <br /> 66 <br /> I - 7" <br /> I 9'- - <br /> 104 <br /> 11 . <br /> 12. <br /> IV. CERTIFICATION SY 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 239 <br /> Division 3, Chapter 16, Section 2716 and all the information provided herein Is accurate. <br /> Designated UST Operator Signature 1J ~ _ . .- . .� <br /> V. d4 OWNER ! OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br /> All Issues listed In Section //l 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 Ill. <br /> 1 . <br /> 21 <br /> I . <br /> _ .. .3'- <br /> 48 <br /> 6. <br /> 79 <br /> 8. <br /> 9. <br /> Ion <br /> 11 . <br /> - 12, <br /> VI. OWNER / OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> I have reviewed Section III "COMPL.IANCE ISSUES" and provided a description in Section V of the action taken or to be taken <br /> to correct the issues discovered. <br /> Name T Owner/Operator (Print) UST Owner/0 erator ' nature Date igned <br /> CERS = CMomia Environmentai Reporting System, ID = identifaatkn, UST = Underground Sorage Tank KC IntemeMonal Code Council <br />