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N <br /> to O <br /> O <br /> r N <br /> O <br /> 0 (6 <br /> i <br /> O <br /> U <br /> N <br /> ry <br /> Appendix Xllr <br /> Undergmund Storage Tank <br /> Designated UST Operator Visual inspection Report <br /> I.FACILRY INFORMATION <br /> 0 CERS 10 <br /> fnspectien bale rn � a� <br /> Q O _ Facility Name irinty Pkwy AM-PM <br /> (, a-' i' Facipry Address <br /> 0 1e7T57rinty Pltwy Clty ZIP Code <br /> C <br /> Stockton 95219 2.DESIGNATED UST OPERATOR INFORMATION 1� <br /> � Name pf Designated U5T Operator nae w� t,ry, 1 <br /> `1 SZ Setrvice SGnpn Maintenance.Inc nine/%( Phone SOcerataY�s+wlkreeecuon Repos <br /> U i f ICD Certificatron �� 975-377-2]etl <br /> f ?0 2 1a 1 Certif-fi n Ex!ration Date i <br /> (6 3.COMPLIANGEISSUE5 <br /> (0 <br /> L �Il:/ Li�U�r(,}< v/nr GrC✓r�rc/rrue. so 1-.,,, Dr."o� �rsw�, 7xin 1� <br /> !1 W/i I �FUNd]B4 e <br /> LL <br /> to tll <br /> ti CIO <br /> O Q <br /> O <br /> O) N <br /> O <br /> 00 N <br /> C7 \ <br /> y00 TM <br /> a <br /> O m <br /> O 4. CERTIFICATION BY DESIGNATED UST OPE,-, CGNDUC ZING INSPECTION x <br /> r <br /> U <br /> Cl California Code <br /> section 2776 and all information Provided <br /> tl <br /> hereby certify that the visual Mspection was performed in compliance with $ <br /> O of Regulations,title 23,division 3,chapter 16, <br /> Q herein is accurate. <br /> L Designate S.T p rat i nature <br /> LO ✓ Date Inspection eport rovided to Owner <br /> Q CERS=CaVomia Environmental Reporting System,ICC=International Code Council,ID= _ <br /> >1 Q Idenlificat7on,NA=Not Applicable,UPC=Under-Dispenser Containment,UST=Underground w <br /> (B Storage Tank g <br /> O O <br /> Page 1 of 4 <br /> X00 <br /> } Ln 0 O <br /> •� \ = N O <br /> � � ao U <br />