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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION 0 Installation Q✓ Repair ❑ 36 Month <br /> 1 . FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181479 2022-01 - 11 <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 ) 588-8737 <br /> Mailing Address <br /> 4780 Cheyenne Way , Chino CA 91710 <br /> Service Technician Performing Inspection <br /> Jamel Hamdan <br /> Contractor/Tank Tester License Number <br /> 703190 <br /> ICC Number Expiration Date <br /> 5244728 12-20-2023 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS EVR Phase 1 Systems VR 101 01 -07-2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI 1200 Industry Standard Mechanical Overfill Valve <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 Date Total # of Pages <br /> 01 - 11 -2022 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council , OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />