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Appendix XIII Tank <br /> Underground storage Inspection Report <br /> Designated UST Operator Visual <br />*LN <br /> 1. FACILITY INFORMATION Inspection Date 05/2��22 <br /> CERS ID 101812378 <br /> ZIP Code <br /> Facility Name WOODBRIDGE AMPM City <br /> Facilit AddW�� <br /> ress DgR�®G� 95258 <br /> y 18806 LOWER SACRAMENTO RD <br /> 2. DESIGNATED UST OPERATOR INFORMATION Phone <br /> Name of Designated UST Operator 209-744-0112 Expiration Date <br /> David Winkler Certification Exp <br /> ICC Certification 2/17/2022 <br /> 8883059-UC <br /> 3. COMPLIANCE ISSUES <br /> Identify by number all compliance issues listed <br /> h F' <br /> -------------- <br /> Y'h <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 UST Operator Signature Date Inspection <br /> Report C Pro <br /> 05/20/22 vided to Owner- - <br /> HERS = California Environmental Reporting System ICC = <br /> do�aigcation, NA = Not Applicable, UDC = Under-DispenserlCon International Code CeUCICi'��_ <br /> Storage Tank tam I, ID ` <br /> ment, UST ; Underground <br /> __ ------- ___ - Page 1 'If 4 <br />