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UNDERGROUND STORAGE TANK <br />FDESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br />I. FACILITY INFORMATION <br />10181513 <br />Date of Designated UST Operator Inspection <br />9/25/2020 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />VAN DE POL ENTERPRISES - RIPON C F N <br />Business Site AddressCity <br />816 E. FRONTAGE ROAD <br />RIPON <br />ZIP Code <br />95366 <br />11. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator (Print as shown on the ICC Certification.) <br />Zane Nimmo <br />Phone # <br />1 (209) 744-0112 <br />ICC Certification # <br />8883064 -UC <br />ICC Certification Expiration Date <br />2/17/2022 <br />III. 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 />2 <br />— <br />5, <br />6, — <br />— <br />7, <br />10. <br />11. _ <br />12. TANKS AND LINES ARE DOUBLEWALL AND DO NOT REQUIRE TESTING _ <br />IV. CER71FICA71ON BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br />1 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 N/ 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 1/1, <br />1. <br />2. <br />3. <br />4. <br />—_ <br />6. <br />7. <br />9. <br />- _ - - _— <br />12. <br />VI, OWNER 1 OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br />I have reviewed Section 111 "COMPLIANCE ISSUES" and provided a description in Section V of the action taken or to be taken <br />to correct the issues discovered. <br />Na//me of UST Owner/Operator (Print) <br />i &4z <br />UST Owner/Op rator Signature <br />I/ <br />i j2v�_ <br />Daattepigne <br />1 <br />CERS = Caifomia Environmental Reporting System, ID = Identiliica w, UST = Underground Stora ffe Tank, ICC = International Code Cmvi <br />