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1403 West Country Club Blvd. PR0231995 <br /> March 29, 2022 Program: UST <br /> PHOTO 2: DO re ort sa s that re ort was rovided to owner on 11/22/2021. <br /> l <br /> gppendix XIII <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> i <br /> 'I 1. FACILITY INFORMATION Inspection Date 11122121 <br /> CERSID 10182103 <br /> I Facility Name United 5446 <br /> City ZIP Code <br /> Facility Address Stockton 952— <br /> 1403 Country Club Blvd. <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Phone <br /> Name of Designated UST Operator 909 455 2275 <br /> Evan elina Barroso-Tra for Certification Expiration Date <br /> ICC Certification 2108123 <br /> 8200889 <br /> "i 3. COMPLIANCE ISSUES <br /> I II •, <br /> I <br /> 4. CERTIFICATIONBYDESIGNATEDUSTOPERATORCONDUCTINGINSPECTION <br /> inconlip <br /> rme <br /> I-hereby certify'*of Regulations,the 23,div cion 3pchalpteron v16,secas tion 2716 and all informati naprovidedlifornia ode <br /> I herein a accurate. <br /> Date Inspection Repo t Provided to Owner <br /> De 'gnaled UST Operator Signature 11/22121 <br /> ID <br /> CERS=California Environmental Reportin System,ICC erCoInternational nment, ST=Council,dre- <br /> Identification,NA=Not Applicable,UDC=Under-Dispenser Containment, Underground 4 <br /> Storage Tank Page 1 of 4 <br /> Lydia Baker, SR. REHS Page 2 of 3 <br />