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- Appendix XIII <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report Wayne Perry Inc. Maintenance Division <br /> 30 Main Avc. . Suitc 5 9281 Commonwullh Ase <br /> I <br /> . CILITY INFORMATION Sacmmcotn. CA.95839 Buena Park CA9062I JobTiekcl NCA <br /> 9635 Commcrcc Avc <br /> ID 10186665 Inspection Date 03/22/2022 San Dago, CA 92121 <br /> Call tD: 5070593 <br /> Facility Name CSI-307709/2218-CHV <br /> Service Station Maintenance Record <br /> Date: 3/ 11 /22 <br /> Facility Address City ZIP Code <br /> Cu <br /> 10858 Trinity Parkway Stockton 95219 slot Name: Chevron ❑ F ❑AB Job!: <br /> Contact Name: [] FF ❑AF Job !: <br /> 2. DESIGNATED UST OPERATOR INFORMATION Station Address: 10858 Trinity Park <br /> Wav Joba NO'WAlOR: 10858 <br /> Name of Designated UST Operator Phone City/Zip: Stockton. CA Facili": 307709 <br /> Andrea Evans 209 699-2648 <br /> ICC Certification Description le Work Performed: <br /> Certification Expiration Date Arrived onsite to inspect diesel fill and turbine wmns for nn ihle wafer intrusion Pound sumps tiShL Check for high water table. No <br /> 10148220 01 /1312024 Inks visible on any penetrations Used obsorbmeni mg and ohsorbed water, tested for fuol and it came back negative Noticed <br /> 3. COMPLIANCE ISSUES condensation forming on turbine and sump lid Wind of minor amount of liquid and olaced hack Into service . <br /> Identify by number all compliance issues listed <br /> 1 . -Follow up from prior report; Site hired new EE, unable to train due to no show no call . <br /> Employee resigned, no follow up action required . Is Job Cuniplcte^ Yes ® No ❑ If No, Comment, _ <br /> 2.-3/11 /2022 L13 : DSL FILL pipping sump fuel alarm-WO# 507593 attached . resting rerrormea^. Yes ❑ No ❑ Hosc ! 21 25 3o other (51 PM A&- vn. It alu <br /> 3 .- Trained three EE's on ER/UST/HMBP required documentation in Emergency Response Hose ! GPM AVrL Reartty <br /> I lose n GPM NL-. Y+L Rauh <br /> Binder. How ! GPM AIL- V1. tte+ults .2222 <br /> 4.-Active employee due for ER/UST/HMBP training . Store manager to schedule training ASAP . Ilose 0 GPM vL. Vol. Rcvull•. <br /> Personnel Timc In Timc Out Rate Iluurs Total <br /> James S liiul <br /> S 000 <br /> S 0 .ou <br /> Part # fart Description i Warrants DOA Vendor Qtv Unit Price I Total <br /> ❑ O .Vu <br /> ❑ ❑� S 0 .00 <br /> O CI s o.00 <br /> ❑ ❑ S o,0o <br /> Authorized Signature: <br /> 4 . CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION <br /> Date: Labor subtotal I S 0.00 <br /> I hereby certify that the visual inspection was performed in compliance with California Code Truscl subtotal <br /> of Regulations, title 23 , division 3 , chapter 16, section 2716 and all information provided Dealer Refused to Sign ❑ Co-op ❑ Third Party ❑ Material Subtotal s 0A <br /> herein is accur GRAND TOTAL. Sf 00 <br /> Designated US erator Signature Date Inspection Report Provided to Owner <br /> : ERS = California nvironmental Reporting System , ICC = International Code Council , ID = Attach 4Lt Rf:CEIPTS and btS-oaf FORtvtS to this Maintenance Record! <br /> lent cation , NA = Not Applicable, UDC = Under- Dispenser Containment , UST = Underground <br /> torage Tank <br /> Page 1 of 4 <br />