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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 110180611 Inspection Date <br /> 9/27/2021 <br /> Facility NameLODI MEMORIAL HOSPITAL <br /> Facility AddressCityS FAIRMONT cityZIP Code <br /> LODI <br /> 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Affords Test 209-744-0112 <br /> Mailing Address 416 2nd St Galt CA 95632 <br /> Service Technician Performing Inspection Edward Stearns <br /> Contractor/Tank Tester License Number 14-1760 Ex. 09/30/2020 <br /> ICC Number8883080-UT <br /> Expiration Date <br /> 11/6/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FF- EBW, Phil-Tite &EVR Phase 1 1009893708 Ex 11/28/2022 <br /> Emco 3205 Ex.02/24/2023 ATG:VR A31048 Ex.7/31/2021 Incon 1009893708 3/1/2023 <br /> OPW 104-635 Ex 3-12-2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> MANUFACTURER OVERFILL VALVE <br /> MANUACTURER PROBE <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. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Ccrvir-c Tcr-hnirrinn Cinnnfi irc Date Total # of Pages <br /> 9/27/2021 5 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />