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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />36 Month <br />00010 <br />1. FACILITY INFORMATION <br />CERS ID <br />10181541 <br />Inspection Date <br />11/19/2021 <br />Facility Name <br />Pacific Bell Telephone Co. dba AT&T California <br />Facility Address <br />1812 Coley Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />TAIT Environmental Services, Inc. <br />Phone <br />(714) 560-8222 <br />Mailing Address <br />11280 Trade Center Dr., Rancho Cordova, CA 95742 <br />Service Technician Performing Inspection <br />Craig Feezell <br />Contractor/Tank Tester License Number <br />588098 <br />ICC Number <br />8374133 <br />Expiration Date <br />06-09-2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root <br />06-14-2023 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />PEI RP 1200 <br />T1 UG0100001 Diesel <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 />.� <br />Date <br />11/19/2021 <br />Total # of Pages <br />CERS =California Environmental Reporting System, ID =Identification, ICC =International Code <br />Council, OPE =Overfill Prevention Equipment <br />Page 1 of 2 <br />