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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION Fn Installation Repair R7 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181241 05/10/2022 <br /> Facility Name <br /> Parkwoods Gas and Food <br /> Facility Address City ZIP Code <br /> 1612 W Hammer Ln Stockton 95209 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contractors (209)461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. <br /> Service Technician Performing Inspection <br /> Mike Kennard <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number Expiration Date <br /> 5254811 07/06/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 104730 NIA <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW Diesel Drop Tube Overfill Valve and Measurements <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 procedures shall be made available upon request by the governing authority. <br /> Service Technician SA nature Date Total # of Pages <br /> 05/10/2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Cade <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />