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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION [M Installation Repair 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10180797 8-2-2021 <br /> Facility Name <br /> Quik Stop Market #39 <br /> Facility Address City ZIP Code <br /> 2285 E . Fremont St Stockton 95205 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Walton Engineering , Inc . 916-373- 1166 <br /> Mailing Address <br /> P . O . Box 1025 , West Sacramento , CA 95691 <br /> Service Technician Performing Inspection <br /> Maxwell Hines <br /> Contractor/Tank Tester License Number <br /> 617238 <br /> ICC Number Expiration Date <br /> 8750053 8/2/2021 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 3/3/2022 <br /> 4 , INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Visual All grade 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 8/2/2021 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council , OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />