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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION E] Installation ® Repair ® 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 12/28/2020 iIS' wA <br /> Facility Name <br /> A&A Gas and Food Mart _ <br /> Facility Address City County Zip Code <br /> 1330 E Yosemite Ave Manteca San Joaquin <br /> ENV <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> BZ Service Station Maintenance 916 -371 -2380 <br /> Mailing Address <br /> 1041 Triangle Ct . , West Sacramento , CA 95826 <br /> Contractor/ Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Inspection <br /> Vic Arneson <br /> ICC Number Expiration Date <br /> 8709495 12 /7/2022 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS Philtite - 1013273708 3/26/2021 <br /> OPW - 165584 9/ 10/2021 <br /> 4 . INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI 1200 Pg . 18 3 drop tubes <br /> 5 . CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> l hereby certify that the OPE was inspected in accordance with California Code of Regulations, title <br /> 23, division 3, chapter 16, section 2637. 2; that required supporting documentation is attached,• and <br /> a# information contained herein is accurate. / understand that test procedures shall be made <br /> availab/e upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 1 /8/2021 <br /> Page 1 of 2 <br />