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Appendix IX 210414"312 <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair m 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181479 05 /24/21 <br /> Facility Name <br /> Mid City Ca FO Regen <br /> Facility Address City ZIP Code <br /> 13850 Devries Road Lodi 95242 <br /> 2 , SERVICE TECHNICIAN INFORMATION ' <br /> Company Performing the Inspection Phone <br /> SunWest Engineering Constructors, Inc . ( 888 ) 5884737 <br /> Mailing Address <br /> 4780 Cheyenne Way , Chino , CA 91710 <br /> Service Technician Performinq Inspection <br /> Kraig Kinder <br /> Contractor/Tank Tester License Number <br /> CA- 703190 <br /> ICC Number Expiration Date <br /> 8296393 11 / 18/22 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Pnumercator 2/ 16/23 <br /> Franklin Fueling 5 /29/22 <br /> 4. INSPECTION PROCEDURES INFORMATION ' <br /> Inspection Procedures Used Components Inspected <br /> Industry Code EBW Drop tube flapper valve <br /> Industry Code Pnumercator Automatic tank gauge <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 /> Og"ally signed by Kraig Kinder <br /> Kraig Kinder. ae002021 ,052412:01 :12 05 /24/21 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council , OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />