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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION Installation ® Repair r 36 Month <br /> ��ILT'Y Ill1iF't]RMAeTE01�1 x <br /> CERS ID Inspection Date <br /> JOW1335 T2 ► <br /> Facility Name <br /> ('�� , t-ex <br /> Facility Address City ZIP Code <br /> �. os t-vv� 95207 <br /> �I <br /> "*zotTrepINS i N I I QI I A Ic a <br /> Company Performing the Inspection Phone <br /> Wayne Perry Inc 916-646-9680 <br /> Mailing Address <br /> 30 Main Ave Suite 5 Sacramento, CA 95838 <br /> Service Technician Performing Inspection <br /> Contractor/Tank Tester License Number <br /> 300345 <br /> ICC Number Expiration Date <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Inspection Procedures Used Components Inspected <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. l understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Se ipe Technici -Signature Date Total# of Pages <br /> CERS = California Environmental Deporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />