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� C�� o 0 rn � <br /> N 3 � � N <br /> –n (D O CQ U <br /> 0 7 C;- 0- Z3 :3v <br /> QO 5. W <br /> 0 (D <br /> O � (DE <br /> M 0- 0 <br /> = UNDERGROUNDSTORAGETANK Q CD <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Pae 1 of 2) h Z <br /> I. FACILITY INFORMATION CD O <br /> CERS ID Date of Designated UST Operator Inspection — <br /> 10180819 7/10/2020 CL O -- (O <br /> Businoss Name(Same as Facility flame or DBA-Doing Business As) O 0 <br /> MY MINI MART (D Q <br /> Business Site Address City ZIP Code _ <br /> 1756 N.WILSON WAY STOCKTON 95205 00 0 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION —, 0 <br /> Name of Designated UST operator(Print as shown on me;CC Gurtificafion.) Phone# <br /> Edward Stearns (209)744-0112 0- <br /> ICC Certifw[ion# ICC Cerlirwation Expiration Date O <br /> 8883080-UC 2/23/2020 T. Z3777 <br /> III. COMPLIANCE ISSUES Q CD 0 <br /> Ail answers of"W or"NA"in sections Vfl through Xf must be cxplainod in this section and may require foftow-up action. CD Q Z3 <br /> 1. SITE HAD WATER LEAK ON MONITOR PANEL PRINTER NOT WORKING n o C7 <br /> 2. WILL INSTALL NEW VEEDER ROOT n c0D D <br /> 3. <br /> 4. _ <br /> 5. (D --s (D <br /> 6. (D -0 <br /> 7. �O <br /> 8. 3 Cn Q <br /> 9. <br /> 10. (D <br /> CD <br /> 11. NO ALARMS TO REPORT 3 <br /> 12. SECTION X TANK AND LINE TESTING NOT REQUIRED 0- (n <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION a O �_ O <br /> 1 hereby certify that the visual inspection was performed in full compliance with California Code of Regulations,Title 23, (D(D Z5 <br /> Division 3,Chapter 16,Section 2715 and all the information provided herein is accurate. U) zT <br /> Designated UST Operator Signature - Cf) (D <br /> V. OWNER I OPERATOR DESCRIPTION OF FOLLOW-UP ACTIONS � (p <br /> All issues fisted in Section ill ahove must have a description of the follow-up action taken orto be taken to correct the issue on the numberC: <br /> line that corresponds with the number fine of the compliance issue listed above in Section Ill. Q CCDD <br /> 2. z NO U) <br /> 3. D 0 <br /> 4. O <br /> 5. v O <br /> 6. CD <br /> 7. Z3 <br /> 0 <br /> CD <br /> 8. 0 U) -0 <br /> s. (D * 0 <br /> 10. CSD C/3 <br /> CD <br /> 11. O <br /> 12. CD <br /> CD ;hTCD n <br /> VI. OWNER!OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUESQ C CD <br /> CD <br /> have reviewed Section III"COMPLIANCE ISSUES"and provided a description in Section V of the action taken orto betaken D O <br /> to correct the issues discovered. C) <br /> Name of UST owner/Operator(Print) UST Ownerloperator Signature ; O <br /> Date Signed � �. � <br /> �sE-t dC�'A t). f 20 za n v ° c <br /> CERS=rafromia F '�ReporOg Systern,ID=Idon664ton,U57=tx yrot,td storage loc=Irdematimal Code Caur- O Z O <br /> CDD co 3 <br /> Cn W <br /> O nCD <br /> O <br /> N CQ <br /> 0 <br />