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i' Appendix XIII <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> 1. FACILITY INFORMATION <br /> CERS ID 10844113 Inspection Date <br /> Facility Name Harney Lane 76 <br /> City ZIP Code <br /> Facility Address 95240 <br /> 141 E. Harney Lane Lodi <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Name of Designated UST OperatorPhone <br /> BZ Service Station Maintenance, Inc _ ,tr5, 916-371-2380 <br /> ICC Certification Certification Expiration Date <br /> 3. COMPLIANCE ISSUES - <br /> D <br /> I <br /> i <br /> 4. Gr r2TIFICATION 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 accura e. <br /> Designated UST Operat r Signature Date Inspection Report Provided to Owner <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 /> A <br />