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1111 E. Kettleman, Lodi, CA 95240 PR0506724 <br /> 06/15/2022 Program: UST <br /> PHOTO 3: <br /> 5/27/22 designated operator inspection report has incorrect overfill date (page 1) <br /> Appendix Xlll <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> 1. FACILITY INFORMATION <br /> CERSID 10182257 <br /> __--_ Inspection Date 05=27=202.2 <br /> Facility Name – - - _ - -- — - <br /> WINE COUNTRY 76 <br /> Facility Address CityZIP Code <br /> 1111 KETTL€MEN LANE LODI 95642 <br /> 2. D€SIt`,NAT€D UST OPERATOR INFORMATION <br /> ame of Designated UST <br /> Felix ROperator_smirez Phone <br /> 209-744-0112 <br /> ICC Certification Certcatiari Expiration Date <br /> 8883072-UC 02-15-2024 <br /> 3. COMPLIANCE ISSUES <br /> Identify by number ell compliance issues list®d <br /> NO TANKS OR LINE TESTING NEEDED <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 /> Desiqnated UST Operator Siqnature Date Inspection Report Provided to Owner <br /> 05-27-2022 <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 /> VICKY VANG-LEE, REHS Page 3 of 4 <br />