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1111 E. Kettleman, Lodi, CA 95240 PR0506724 <br /> 06/15/2022 Program: UST <br /> PHOTO 1: <br /> 3/3/2022 designated operator inspection report missing date owner/operator signed (page 1) <br /> Report Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> s No NA <br /> Date last d 1• FACILITY INFORMATION <br /> performed CERS ID 10182257 -_ <br /> ❑ ____ Inspection Date 3/3/22 <br /> 6/16/21 Facility Name WINE COUNTRY 76 <br /> ❑ ❑ 6/16/21 Facility Address 1111 EAST KETTLEMAN LN City LODI Zip Code 95240 <br /> ❑ EJ 6/16/21 2. DESIGNATED UST OPERATOR INFORMATION <br /> ❑ <br /> Name of Designated UST Operator Amy Winkler <br /> 12/22/20 Phone 209-744-0112 <br /> ❑ ❑ ICC Certification 9951352-UC Certification Exp Date 3/26/2023 <br /> 3. COMPLIANCE ISSUES <br /> I Identify by number all compliance issues listed <br /> ✓ I <br /> I <br /> Yes No <br /> �ty z ❑ <br /> compliance <br /> 4. CERTIFICATION BY DESIGNATED UST OPERATOR CONDUCTING INSPECTION <br /> I hereby certify that the visual inspection was performed in compliance with California qCode <br /> of Regulations,title 23, division 3, chapter 16,section 2716 and all information provide <br /> herein is accurate. <br /> Designated UST Operator Signature Date Inspection Report Provided to n11 3 <br /> /3/22 <br /> _a/ { CERS = California Environmental Reporting System, ICC= International Code Council, ID= <br /> 3. . Identification, NA= Not Applicable, UDC= Under-Dispenser Containment, UST= Underground <br /> Pana d r f n Storage Tank <br /> VICKY VANG-LEE, REHS Page 1 of 4 <br />