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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 10181579 <br />Inspection Date <br />10/19/2021 <br />Facility Name <br />Tracy Unifed School District - Service Center <br />Facility Address <br />1975 W. Lowell Ave <br />City <br />Tracy <br />ZIP Code <br />95376 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection Phone <br />Bagley Enterprises, Inc 209.367.4800 <br />Mailing Address <br />2370 Magaio Cir #4 Lodi CA 95240 <br />Service Technician Performing Inspection <br />Andrew Bagley <br />Contractor/Tank Tester License Number <br />774802 <br />ICC Number <br />8012449 <br />Expiration Date <br />11/12/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />OPW <br />1/22/2022 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used Components Inspected <br />Manufacters Recommended Prac ice Overfill Prevention Valve <br />6. 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. l understand <br />that test procedures shall be made available upon request by the goveming authority. <br />Service TechnicianSign a <br />A . 1-- <br />Date <br />10/19/2021 <br />Total # of Pages <br />2 <br />CERS = California Environ tal Meportinoystern, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />