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Appendix IX 21200044 <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION Installation Repair F136 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181263 1/19/2021 <br /> Facility Name <br /> Arco 6080 <br /> Facility Address City ZIP Code <br /> 85 E. Louise Ave. Lathrop 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Gettler-Ryan Inc. 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 94568 <br /> Service Technician Performing Inspection <br /> Damell Smith <br /> Contractor/Tank Tester License Number 220793 <br /> ICC Number Expiration Date <br /> 8709494 111/23/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root Tech Gert #48857 3/23/2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Tank Chart/Tape Measure Veeder Root TLM Probes <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> 1 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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 1/19/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />