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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 />Page 1 of 2 <br />TYPE OF ACTION Installation Repair 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181511 <br />Inspection Date <br />09/1 /2024 <br />Facility Name <br />Boyett Petroleum #98 / Kwik Serv <br />Facility Address <br />2501 Jackson Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />CGRS, Inc. <br />Phone <br />(916) 991-1100 <br />Mailing Address <br />5444 Dry Creek Road; Sacramento, CA. 95838 <br />Service Technician Performing Inspection <br />Leo Rangel <br />Contractor/Tank Tester License Number <br />CSLB#803616 <br />ICC Number <br />8711887 <br />Expiration Date <br />07/07/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />OPW UST EVR Phase 1 Cert.# 0167932 0 <br />F.F.S. EVR Phase 1 Systems – VR-101 Cert.#1004793709 0 <br />Universal 47-20 Waste Oil Cert. #122224-2 01/24/2026 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used Components Inspected <br />RP-1200 / Manufacture’s IOM Overfill Valves / Drop Tubes <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 <br /> Leo Rangel <br />Date <br />09/1 /2024 <br />Total # of Pages <br />8