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Appendix XIII <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> 1. FACILITY INFORMATION <br /> CERS ID 10180717 Inspection Date 10/17/2021 <br /> Facility Name Chevron <br /> Facility Address City ZIP Code <br /> 10878 N Hwy 99 <br /> Stockton 95212 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Name of Designated UST Operator Phone <br /> Adam Smitheram (916) 704-694$ <br /> ICC Certification Certification Expiration Date <br /> 9084899 1/22/2023 <br /> 3. COMPLIANCE ISSUES <br /> S0#61 00 <br /> Monitor States: All Functions Normal <br /> - No recent liquid alarms <br /> No issues <br /> 4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION <br /> I hereby certify that the visual inspection was performed incompliance with California Code <br /> of Regulations, title 23, division 3, chapter 16,section 2716 and all information provided <br /> herein is accurate. <br /> Designated T perator Si ure Date Inspection Report Provided to Owner <br /> 10/17/2021 <br /> CERS = California Environmental Reporting System, ICC = International Code Council, ID= <br /> Identification, NA= Not Applicable, UDC = Under-Dispenser Containment, UST= Underground <br /> Storage Tank <br /> Page 1 of 4 <br />