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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br /> <br />Page 1 of 2 <br />TYPE OF ACTION ☐ Installation ☐ Repair ☒ 36 Month <br />1. FACILITY INFORMATION <br /> <br />CERS ID <br />10397599 <br />Inspection Date <br />11/18/21 <br /> <br />Facility Name <br />Sutter Tracy Community Hospital <br /> <br />Facility Address <br />1420 N. Tracy Blvd. <br />City <br />Tracy <br />ZIP Code <br />95376 <br /> <br />2. SERVICE TECHNICIAN INFORMATION <br /> <br />Company Performing the Inspection <br />Alltech Petro, Inc. <br />Phone <br />209-532-7320 <br /> <br />Mailing Address <br />P.O. Box 4208 Sonora CA, 95370 <br />Service Technician Performing Inspection <br />Isaac Anderson <br />Contractor/Tank Tester License Number <br />09-1749 <br /> <br />ICC Number <br />8146912 <br />Expiration Date <br />09/10/22 <br /> <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />OPW #100456 05/11/22 <br /> <br /> <br /> <br />4. INSPECTION PROCEDURES INFORMATION <br /> <br />Inspection Procedures Used Components Inspected <br />PEI RP-1200/ Diesel Tank <br /> Manufacturer <br /> <br /> <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <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. I understand <br />that test procedures shall be made available upon request by the governing authority. <br /> <br />Service Technician Signature Date <br />11/18/21 <br />Total # of Pages <br />2 <br />