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Appendix IX <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 /> 10181511 3/28/22 <br /> Facility Name <br /> KWIK SERV ESCALON <br /> Facility Address City ZIP Code <br /> 2501 JACKSON AVE TIESCALON 95320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> LC SERVICES (559) 444-1730 <br /> Mailing Address <br /> 3887 N VALENTINE AVE FRESNO CA 93722 <br /> Service Technician Performing Inspection <br /> CHARLES SHRABEL <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number Expiration Date <br /> 9477557 12/6/21 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VR #C28984 10/22 <br /> VMI #4778 9/22 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> MANUFACTURER 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 Sig lure Date <br /> To.2I # 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 />