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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 10181401 Inspection Date <br /> 1/18/2021 <br /> Facility Name VAN DE POL - LODI PACIFIC PRIDE <br /> Facility Address ZIP Code <br /> 351 N BECKMAN ROAD City L O D 1 <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 <br /> Zane Nimmo <br /> Contractor/Tank Tester License Number 04-1676 Ex.03/31 /2022 <br /> ICC Number Expiration Date <br /> 8883064-UT 06-01-2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> EBW , Phil-Tite & EVR Phase 1 10009843708 Ex 11-30-22 <br /> OPW 104-632 Ex 3-17-2022 Emco 3206 Ex. 11/14/2022 <br /> ATG: VR: A28446 Ex. 10/2/2021 Incon # 1009843708 Ex.11-30-22 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW ALL 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 /> Ccrvir-c Tcr-hnirrinn Cinnnfi irc Date Total # of Pages <br /> 1/18/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />