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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION 0 Installation © Repair © 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10180667 <br />Inspection Date <br />5-19-2021 <br />Facility Name <br />Quik Stop Market #121 <br />Facility Address <br />1196 W Louise Ave <br />City <br />Manteca <br />ZIP Code <br />95336 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Walton Engineering <br />Phone <br />916-372-1888 <br />Mailing Address <br />9300 Commerce Drive <br />Service Technician Performing Inspection <br />Anthony Reyes <br />FContractor/Tank Tester License Number <br />617238 <br />ICC Number <br />8293772 <br />Expiration Date <br />8-2-2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW Phase 1 EVR 103920 <br />6-20-2021 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />OPW Install & Maintenance Guideline <br />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 />Service Technician Signature <br />/19t'131 <br />Date <br />4-20-2021 <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 />