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1225 W. Lockeford St, Lodi, CA 95240 PR0231350 <br /> 11/23/2021 Program: UST <br /> PHOTO 6: <br /> 09/17/2021 designated operator(DO) monthly report has incorrect overfill prevention test date <br /> vcaryr raLG Wr I vel aavr viaua. —Viijurc t <br /> U 10. TESTING AND MAINTENANCE Yes No NA Date Appendix XIII <br /> last <br /> Underground Storage Tank performe <br /> 1. F �estgnated UST Operator O Visual inspection Report Has monitoring system certification been completed within the past <br /> ACILIry INF P Pe P O ❑ 11/2512020 <br /> ORNIATION 12 months? <br /> S ID 1p181313 Has spill container testing been completed within the past 11 ❑ 11/25/2020 <br /> acility Name Inspection Date g/17/2021 12 months? <br /> Facie LODI FOOD g, LIQUOR Has overfill prevention equipment inspection been completed within IZ/ 0 ❑ 1/11/2019 <br /> Facility Address the past 36 months? <br /> 1225 W. LOCKEFORD STREET YL O D 1 <br /> ZIP <br /> -las seconds containment testin been completed within the past <br /> 2. DESIGNATED secondary g P ❑ ❑ 212612020 <br /> Name t n UST OPERATOR INFORMATION I 36 months? <br /> Zane Nimmo gnated UST Operator Phone ias tank tightness testing been completed within required <br /> 13 11 ❑ <br /> ICC Certification los X44 ottz imeframes? <br /> 8883064-UC Certification Expiration Date <br /> las line tightness testing been completed within the required <br /> 3. COMPLIANC vt�/2ozz meframes? <br /> E ISSUES <br /> ldentib st/Maintenance: 0 11 [DrY y number al/compliance issues listed Ither Te <br /> ther Test/Maintenance: 0 ❑ <br /> ther Test/Maintenance: ❑ ❑ <br /> FACILITY EMPLOYEE TRAINING Yes No <br /> Ive all individuals performing facility employee duties received the required facility <br /> Iployee training within the past 12 months? <br /> � COMMENTS <br /> „ s section maybe used to record comments or observations that are not current compliance <br /> iciencies. <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 /> Designated USTOperator Siqngture - DatInspection Report Provided to Ownet <br /> m,ICC=International Code Council,ID <br /> CERS=California Environme�nbletalRUDC eport1=UnderSysteDispenser Containment UST Underground <br /> Identification,NA=Not App <br /> Storage Tank ers marked'No"must be described by the designated UST operator in Section 3. <br /> Page 1 of Page 4 of 4 <br /> VICKY VANG-LEE, REHS Page 6 of 8 <br />