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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 Inspection Date <br /> 10156057 110-08-2021 <br /> Facility Name <br /> UPS <br /> Facility Address City ZIP Code <br /> 1532 North Broadway Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> RL Stevens Co 510-889-0908 <br /> Mailing Address <br /> P.O. Box 361 San Leandro CA 94577 <br /> Service Technician Performing Inspection <br /> David Pereira <br /> Contractor/Tank Tester License Number <br /> 415807 <br /> ]CC Number Expiration Date <br /> 5240739 07/28/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 07/28/2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI-12001opw worksheet Overfill Drop Tube <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. I understand <br /> that test pr ures shall be made available upon request by the governing authority. <br /> Service T ignature Date Total #of Pages <br /> 10-08-2021 6 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 9 of 2 <br />