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Appendix XIII <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> 1 . FACILITY INFORMATION <br /> CERS ID ' Inspection Date <br /> Facility Name <br /> Facility Address City I OnfN J CIT <br /> ZIP Code/ <br /> Cj <br /> 2 . DESIGNATED UST OPERATOR INFORMATION <br /> Name of De 'gnated UST Operator Phone <br /> tEj�ed6 - 2, 6P37� 7 <br /> ICC Certificatio© � ��,, / � Certificati n Expiration Date <br /> b <br /> 3 . COMPLIANCE ISSUES <br /> 4nuo \ �G( Wl() r � \ u <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 /> Design t ST ignature 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 /> UN-111 www.unidocs .org Rev. 10/01 /20 Page 1 of 4 <br />