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UNDERGROUND STORAGE TANK <br /> DESIGNATED UNDERGROUND STORAGE TANK OPERATOR VISUAL INSPECTION REPORT(Paye I of 2) <br /> _ I. FACILITY INFORMATION <br /> CERS ID Date of Design ted UST Operator Inspection <br /> 10181579 � � <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> TRACY UNIFIED SCHOOL DISTRICT <br /> Business Site Address City ZIP Code <br /> 1975 W LOWELL AVE TRACY 95376 <br /> II. DESIGNATED UNDERGROUND STORAGE TANK OPERATOR INFORMATION <br /> Name of Designated UST Operator(Print as shown on the ICC CerfiBcation.) Phone# <br /> Andrew Bagley (209)367-4800 Ext. <br /> ICC Certification# ICC Certification Expiration Date <br /> 8012449 17/19/2020 <br /> III. COMPLIANCE ISSUES <br /> All answer of"N"or"Win sections Vll through X1 must be explained in this section and may require follow-up action. <br /> 1. Tank tightness test-double wall tank- N/A <br /> 2. Line tightness test-fail safe <br /> 3. 3D Co 1�I p"�S�.L g RST e4[AlL/Y1 n�srlZ <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> 11. <br /> 12. <br /> IV. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING THIS INSPECTION <br /> 1 hereby certify that the visual inspection was perfor full compliance with California Code of Regulations,title 23, <br /> division 3,chapter 16,section 2716 and all the info atiprovided herein is accurate. <br /> Designated UST Operator Signature <br /> V. OWNER/OPEATOR DE ON OF FOLLOW-UP ACTIONS <br /> All issue listed in section Ill above,must have a description of the folio -up actio ken,or to be taken,to correct the issue on the number line that <br /> corresponds with the number line the compliance issue is listed above In section ill. <br /> 1. Tank tightness test-double wall tank- N/A <br /> 2. Line tightness test-fail safe65DXSZ <br /> 3. �/j 90 -- ! `LLL`457- 5i4aaP r4L,g2 rn e-C& <br /> 4. <br /> 5. <br /> 6. <br /> 7. <br /> 8. <br /> 9. <br /> 10. <br /> 11. <br /> 12. <br /> V1. OWNER/OPERATOR ACKNOWLEDGMENT OF COMPLIANCE ISSUES <br /> I have reviewed section III"COMPLIANCE ISSUES"and provided a description in section V,of the action taken or to be taken <br /> to correct the issues discovered. <br /> ---- — --- — -- <br /> Name of UST Owner/Operator(Print) ST Owner/Operator Signature Date Pigneq <br /> CERS=Caltfomia Environmental Reportina System,ID=Identification,UST=Underground storage tank ICC=International Code Council <br />