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078117PAMIRBF-11A <br />Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION F Installation Test Repair Test 36 Month Test <br />1. FACILITY INFORMATION <br />CERS ID <br />10181335 <br />Inspection Date <br />2/18/2021 <br />Facility Name <br />CHEVRON # 94275 <br />Facility Address <br />2905 W. BENJAMIN HOLT @ 1-5 <br />City <br />STOCKTON <br />Zip Code <br />95207 <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 />Brent Bowen <br />Contractor/Tank Tester License Number <br />Class A General Engineering 743160 <br />ICC Number <br />8211862 <br />Expiration Date <br />6/8/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />ICC -CA UST Service Technician 8211862 <br />06/08/2023 <br />CA -Tightness Testing 14-1759 <br />08/31/2023 <br />OPW-EVR Phase 1 100255 <br />01/05/2022 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedure Used <br />Components Inspected <br />OPW <br />Drop Tubes <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 />Service Technician Signature <br />�' <br />Date <br />2/18/2021 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />https://tancs.tanknology.com/TANCS.aspx?4481441715825 1/2 <br />