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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION 0Installation El Repair X 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10184915 <br />Inspection Date <br />5/3/2022 <br />Facility Name <br />Shell 1-5 <br />Facility Address <br />717W 8th Street <br />City <br />Stockton <br />ZIP Code <br />95206 <br />SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Pinnacle Fuel Compliance <br />Phone <br />408-206-9840 <br />Mailing Address <br />P.O. Box 32849 <br />Service Technician Performing Inspection <br />Aneil Chand <br />Contractor/Tank Tester License Number <br />90-1262 <br />ICC Number <br />8455316 <br />Expiration Date <br />5/27/2022 <br />TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Veeder Root Cert# A21783 3/12/2024 <br />Franklin Fueling System Cert#1001943708 4/13/2024 <br />OPW Cert # 100208 4/21/2023 <br />INSPECTIONPROCEDURES INFORMATION <br />Ins pectionProcedures Used Components Inspected <br />Mfg Installation Overfill Droptube <br />CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />I hereby certify that the OPE was inspected in accordance with California Code of Regulations, title <br />23, division 3, chapter 16, section 2637.2; that required supporting documentation is attached; and all <br />information contained herein is accurate. I understand that test procedures shall be made available <br />upon request by the governing authority. <br />- <br />-<---->w (---- Date <br />5/3/2022 <br />Total # of Pages <br />8 Service Technician Signature _ <br />OVERFILL PREVENTION EQUIPMENT DETAILS <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2