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Appendix IX 012-A,tIl <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 /> 10180661 21912. <br /> Facility Name <br /> One Stop Market <br /> Facility Address City ZIP Code <br /> 1151 W Louise Ave Manteca 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contractors (209)461-6336 <br /> Mailing Address <br /> 2535 WDr. Stockton CA 95205 <br /> Service echnician Performing Inspection <br /> Ben'amin Malaspina <br /> Contractor/Tank Tester License Number <br /> 1001331A-HAZ <br /> iCC Number Expiration Date <br /> 9519380 2126122 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW EVR UST 0182799 5119123 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW Drop tube overfill valve <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING IN <br /> I hereby certify that the OPE was inspected in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 96, 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 /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />