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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION K Installation ❑ Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 1/14/2021 <br /> Facility Name <br /> Waterloo Liquor <br /> Facility Address City County Zip Code <br /> 2512 Waterloo Rd Stockton .T 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contractors 209 461-6337 <br /> Mailing Address <br /> 2535 Wigwam Drive <br /> Contractor/ Tank Tester License Number <br /> 101331- HAZ <br /> Service Technician Performing Inspection <br /> Gilbert Garcia <br /> ICC Number Expiration Date <br /> 1864 6/19/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling Systems FFS EVR Phase I Systems VR-101 3/26/2021 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> 1 hereby certify that the OPE was inspected in accordance with California Code ofRegulations,title <br /> 23,division 3, chapter 16,section 2637.2;thatrequired supporting documentation is attached,and <br /> all information contained herein is accuratel understand that test procedures shall be made <br /> available upon request by the governingauthority. <br /> Serv' e T cian Signature Date Total #of Pages <br /> j 1/14/2021 2 <br /> Page 1 of 3 <br />