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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION Installation Test r Repair Test r 36 Month Test <br />1 1. FACILITY INFORMATION <br />CERS ID Inspection Date <br />10165777 10/22/2020 <br />Facility Name <br />7 -ELEVEN 14113, MKT 2368 <br />Facility Address <br />3040 BENJAMIN HOLT DR @ GRIGSBY <br />City <br />STOCKTON <br />Zip Code <br />95219 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Tanknology, Inc. <br />Phone <br />(800) 800-4633 <br />Mailing Address <br />11000 N. MoPac Suite 500, Austin, Tx. 78759 <br />Service Technician Performing Inspection <br />Clint Fuhrman <br />Contractor/Tank Tester License Number <br />Class A General Engineering 743160 <br />ICC Number <br />9160945 <br />Expiration Date <br />5/2/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />ICC -CA UST Service Technician 9160945 <br />05/02/2021 <br />OPW-EVR Phase 1 904272 <br />05/23/2021 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedure Used <br />Components Inspected <br />OPW 71 SO INSTRUTIONS <br />DROPTUBES <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />I hereby certify that the OPE was inspected in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting <br />documentation is attached; and all information contained herein is accurate. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />10/22/2020 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />