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_ , <br /> � <br /> o M > ° O <br /> • o 0o <br /> � G <br /> m ® Nv <br /> N Q �# N � <br /> oo <br /> _ — D <br /> mv o <br /> _ (D C/) <br /> U) m <br /> Appendix X411 �0 < <br /> �. <br /> Underground Storage Tank m <br /> Designated UST Operator Visual Inspection Report j <br /> m <br /> n <br /> t. FACILITYlNFORMATION Inspection pate 511912029 N <br /> CERSID 10184725 <br /> Cn <br /> Facility Name West Valley Auto Service LLC lip Code <br /> City l 98304 <br /> Facility Address Tracy N <br /> o <br /> 2615 W Grant Line RD iv <br /> 2. DESIGNATED UST OPERATOR INFORMATION phone r <br /> Name or Designated UST Operator (9 5)899-1396 0, <br /> Rick Branchini <br /> Certification Expiration Date m ;U <br /> ICC Certification 6/212022 0- <br /> ° <br /> 8164986 1 <br /> 3. COMPLIANCE ISSUES 0 v <br /> 0 <br /> GVR TLS-350 AFN this period ok 8:19 AM rp <br /> Nothing to report this period 0 D <br /> Monitor and Spill bucket certification 3!3112021 Cfl <br /> Return to compliance submitted 5115121 Communication within this report v O <br /> Need SB-989 test results See testing 516!21 <br /> F)7 CD <br /> N <br /> N <br /> p <br /> iN <br /> 4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION <br /> I hereby certify that the visual inspection was performed in compliance with California Code <br /> of Regulations, title 23, division 3, chapter 16, section 2716 and all information provided <br /> herein is accurate. <br /> Designated UST Operator Signature Date Inspection Report Provided to Owner <br /> n p n Digitally signed by Rick Branchini <br /> Dale:2021.05.19 08:57:27-07' 51191242100' � <br /> m <br /> CERS=California Environmental Reporting System, ICC = International Code Coun Il, lD = 0 <br /> Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, UST = Underground <br /> v Storage Tankcc <br /> o <br /> m � <br /> UN-til g Rev.10+0t12o Page 1 of 4 0 <br /> 0 www.tinidocs.org <br /> Cn <br /> Ca <br /> v <br />