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Appendix X111 <br />-- erground Storage Tank <br />Operator Visual Inspection Report <br />-------- - — - <br />1. SHELL <br />W KETTLEh'lAN LN --- ---- - -- --- --- ------ <br />CE L4DI.CA 95240 Inspection Date 3/2312023 <br />Fa( f`1HR 23. 2023 5:27 FM— <br />IFa( City ---- --_--- ZIP Code <br />420 `'STEM STATUS •REP}RT I_Odi 195240 <br />�I ALL FUN( -TIONS NORt•IAL NFORMATION <br />FNan s Phone <br />Ren(209) _ _ (209) 518-4836 <br />ICC Certification Expiration Date <br />8032 10/22/2024 <br />13. C <br />--- ALARM HISTORY REPORT ---------- -- - --- -- <br />SEI•d 101R ALARM <br />----- <br />L 1* 87 SPF• <br />S"! P :;Uh1P <br />FUEL. H rikh c c PM <br />FEB '27. :'023 1 *2: ./ <br />FUEL HLHRM <br />FEB ?7 . 202:3 9: 27 At11 <br />t <br />SETUP I1HTH WmRI41 NG moi` <br />FEB 27. 202:3 9 <br />4' <br />* * * * * END * * * * x <br />F <br />4. CE �ALHRM HISTORY REPORT 3 UST OPERATOR CONDUCTING INSPECTION <br />I here - --- SENSOR ALAhr1 .tion was performed in compliance with California Code <br />of Ret „� .tea ur Tr,rs. �r..c _. -hapten 16, section 2716 and all information provided <br />herein -is -accurate. <br />---- ---- - _—--- -- --------------------------------------- <br />Dgsig ated;UST Open or Siginature, Date Inspection Report Provided to Owner <br />i <br />3/23/2023 <br />CEF,S = California viron mental 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. 10101/20 Page 1 of 4 <br />