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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION F Installation Test Repair Test r <br />P 36 Month Test <br />1. FACILITY INFORMATION <br />CERS ID <br />10181335 Inspection Date <br />2/18/2021 <br />Facility Name <br />CHEVRON # 94275 <br />Facility Address City =95207� <br />de <br />2905 W. BENJAMIN HOLT a@ 1-5 STOCKTON <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection Phone <br />Tanknology, Inc. (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 Expiration Date <br />8211862 6/8/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />JExpiration Date <br />ICC -CA UST Service Technician 8211862 6/08/2023ICC-Vapor Recovery System Testing & Repair 8211862 0/27/2022 <br />OPW EVR Phase 1 100255 01/05/2022 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedure Used Components Inspected <br />Opw Droptubes <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, 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />2/18/2021 <br />CERS = California Environmental Repor y ;>ystem. ID = IdentnrCauon. KL; = International Code <br />Council. OPE = Overfill Prevention Equipment <br />Total # of Pages <br />2 <br />