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Appenam mm <br />Underground Storage Tank <br />Designated UST Operator Visual Inspection Report <br />,1. FACILITY INFORMATION <br />A inspection Date 11/22/21 <br />,C <br />ERS ID 10182103 p <br />Facility Name United 5446 <br />FacilityAddress <br />1403 Country Club Blvd. <br />City ZIP Code <br />Stockton 195204 <br />2. DESIGNATED UST OPERATOR INFORMATION <br />Name of Designated UST Operator <br />Evangeline Barroso-Traylor <br />ICC Certification <br />8200889 <br />one <br />909 455 2275 <br />Certification Expiration Date <br />2108!23 <br />3. COMPLIANCE ISSUES <br />U K <br />4. 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 />DegnatedUST Operator Signature <br />Date Inspection Report Provided to Owner <br />11/22/21 <br />CERS =California Environmental Reportin 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 />