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r Appendix XIII <br /> Underground Storage Tank <br /> Designated UST Operator Visual Inspection Report <br /> 1. FACILITY INFORMATION <br /> CERS ID 10181239 Inspection Date 03-08-2023 <br /> Facility Name A AND A GAS AND FOODO <br /> Facility Address Cit ZIP Code <br /> City <br /> 16 EAST HARDING WAY ON 95204 <br /> 2. DESIGNATED UST OPERATOR INFORMATION <br /> Name of Designated UST Operator Phone <br /> Felix Ramirez 209-744-0112 <br /> ICC Certification Certification Expiration Date r <br /> 8883072-UC 02-1-2024 <br /> 3. COMPLIANCE ISSUES <br /> Identify by number all compliance issues listed <br /> F01 SUfnV) -F UL Cil(Ci�� N <br /> N <br /> � � Z <br /> i W � <br /> 0 <br /> b <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 /> N <br /> rgnated UST Operator Signature Date In Report Provided to Owner c� ' <br /> --- � 103 08-2023 <br /> CERS = California Environmental Reporting System, ICC = International <br /> Identification, NA = Not Applicable, UDC = Code Council, ID <br /> Storage Tank Under-Dispenser Containment, UST = <br /> Underground <br /> Page 1 of 4 <br />