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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ® Installation ❑ Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID inspection Date <br /> 1080655 3/01/2022 <br /> Facility Name <br /> Cherokee Arco <br /> Facility Address City ZIP Code <br /> 3443 Cherokee Rd Stockton 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contrators (209)461-6337 <br /> Mailing Address <br /> 2535 Wi wam Dr. <br /> Service Technician Performing Inspection <br /> Adrian Rodri uez <br /> Contractor/Tank Tester License Number <br /> 1001331 A-HAZ <br /> ICC Number Expiration Date <br /> 9914593 4127123 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 0192139 5/19/2023 <br /> ICC Service Tech 4/27/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW Overfill Valves <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> /hereby certify that the OPE was inspected in accordance with California Code of <br /> Regulations, title 23, division 3, cha _ section 2637.2; that required supporting <br /> documentation is attache nd all informatio ontained herein is accurate. 1 understand <br /> that test procedures all be made available up n request by the governing authority. <br /> Service Technicia ignature =ale Total # of Pages <br /> y -2 2 <br /> C = ali nvironmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />