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Appendix IX Received <br /> Underground Storage Tank 13/10/2023 <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 /> 10181259 03/22/2022 <br /> Facility Name <br /> AJ's Mini Mart Inc. <br /> Facility Address City ZIP Code <br /> 7906 N EI Dorado St. Stockton 95210 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Tank-Tight Systems,Inc. 916-378-4167 <br /> Mailing Address <br /> 1729 Crystal Ct.Olivehurst,CA 95961 <br /> Service Technician Performing Inspection <br /> Brian Roth Sr. <br /> Contractor/Tank Tester License Number <br /> 1066914 A HAZ <br /> ICC Number Expiration Date <br /> 8834817 11/15/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> EMCO Wheaton#3383 11/27/2023 <br /> OPW#1192468 10/21/2023 <br /> Franklin Fueling System#1035133709 10/24/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Measurements with Tank Charts Unleaded Regular E,Unleaded Regular W,Unleaded Supreme,and Diesel#2 OPE <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 /> Service Technician Signature Date Total # of Pages <br /> 03/22/2023 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />