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Appendix X111 <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> 1 . FACILITY INFORMATION <br /> CERS S I D 1018472,E Inspection D@te 3120/2021 <br /> Facility Name West valley Auto Service LLC <br /> Facility Address City ZIP Code <br /> 2615 W Grant Lire ISD Tracy 95304 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Name of Designated IST Operator J- - - - Phone -- <br /> Rick Branchia! , (925) 699-1396 <br /> ICC Certification Certification Expiration Date <br /> 8164986 16/212022 <br /> 3. COMPLIANCE ISSUES <br /> GVR TLS-350 AFN this period ok 3120121 <br /> Nothing to report this period <br /> 4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTINGINSPECTION <br /> I hereby certify that the visual inspection was performed in compliance with Californias Code <br /> of regulations, title 23, division 3, chapter 16, section 2716 and all information provided <br /> herein is accurate. <br /> Designated UST Operator Signature Date Inspection Report Provided to Owner <br /> fD�i�y}f�ty�l�lJ �ign�}�d b�` RickB"�r�}a��c7�ir�i 12012021 <br /> CERS = California Environmental Reporting System, ICC = International Code COLIncil, ID = <br /> Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, UST = Underground <br /> Storage Tank <br /> UN-1 II .unidocs-org Rov. 1o101J;?0 Page I of 4 <br />