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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 10180633 <br />Inspection Date <br />09/07/21 <br />Facility Name SHORT STOP 76 <br />Facility Address <br />20A WEST TURNER RD <br />City LOD I <br />ZIP Code <br />95240 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Affords Test <br />Phone <br />209-744-0112 <br />Mailing Address 416 2nd St Galt CA 95632 <br />Service Technician Performing Inspection David Winkler <br />Contractor/Tank Tester License Number 08-1739 Ex.3/31 /2023 <br />ICC Number8883059-UT <br />Expiration Date <br />1/27/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11/29/22 <br />Emco #3207 Ex. 2/24/23 ATG: VR: B34975 ATG: 2/8/22 INCON 1009853708 Ex. 11/11/2022 <br />OPW 104-633 Ex 3-13-2022 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />OPW <br />FLAPPERS <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 <br />w09/07/21 <br />Date <br />Total # of Pages <br />4 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />