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UNDERGROUND STORAGE TANK <br />FDTESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT (Page 1 of 2) <br />1. FACILITY INFORMATION <br />RS ID <br />10181513 <br />Date of Designated UST Operator Inspection <br />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 <br />816 FRONTAGE RD <br />City <br />RIPON <br />.ZIP Code <br />195366 <br />11, DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br />Name of Designated UST Operator (Print as shown on the ICC Certification.) <br />Felix Ramirez <br />Phone # <br />(209) 744-0112 <br />ICC Certification # 766—certification <br />8883072 -UC <br />Expiration Date <br />3/1/2022 <br />Ill. COMPLIANCE ISSUES <br />All answers of "N" or "Win sections VIl through Xl 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 />3. <br />4. <br />5. <br />6. <br />— �. <br />— <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 rA -. _-- <br />r <br />V. OWNER OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS <br />All issues listed in Section Ill 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 />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />10. <br />11. — <br />12. <br />VII. OWNER 1 OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br />I have reviewed Section Ill "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 T Owner/Operator (Print) <br />UST OwnerlO eratarj nature <br />Date igned <br />CERS = CaHbmia Environmental Reporting System, ID = Idenffmtibn, UST = Underground Storage Tank, & = International Code Council <br />