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Appendix XIII <br /> Underground Storage Tank <br /> Designated LIST Operator Visual Inspection Report <br /> 1. FACILITY INFORMATION <br /> CERS ID <br /> 10594654Inspection12 <br /> Facility Name Pacific Avenue Chevron <br /> Facility Address City 1 ZIP Code <br /> 6633 Pacific Avenue Stockton 95207 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Name of Designated UST Operator Phone <br /> Stephanie MyEphy 1-209-380--5542 <br /> ICC Certification Certification Expiration Date <br /> 19383552 10-1-2021 <br /> 3. COMPLIANCE ISSUES <br /> 14. 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 /> D ated UST Operator Signature Date Inspection Report Provided to Owner <br /> —:1 J—" <br /> C fts-� C`� <br /> E lifornia Environmental Repo in System. ICC = International Code Council, ID <br /> Identification, NA = Not Applicable. UDC = Under-Dispenser Containment, UST = Underground <br /> Storage Tank <br /> Pagel of <br />