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Appendix IX <br />Underground Storage Tank <br />)Verrill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID 10180839 <br />Inspection Date <br />7/3/2024 <br />Facility NameSTOCKTONFOOD & GAS #1 <br />Facility Address 1605 S EL DORADO ST <br />City STOCKTON <br />ZIP Code <br />95206 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />ECO CHEK <br />Phone <br />888-500-2435 <br />Mailing Address PO BOX 1394 Lafayettte <br />Service Technician Performing Inspection Edward Stearns <br />Contractor/Tank Tester License Number 14-1760 Ex. 09/30/25 <br />ICC Number <br />ExpirationExpirat11/5/2024 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11/26/2024 <br />Emco 3205 Ex. 02/24/2025 ATG: VR A31048 Ex. 7/31/2025 Incon 1009893708 3/01/2025 <br />OPW 104-635 Ex 34/2026 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />MANUFACTUR <br />OVERFILL VALVES <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />1 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. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />(�i.*a rGI' 03t['/G> w <br />Date <br />7/3/2024 <br />Total # of Pages <br />2 <br />CERS =California Environmental Reporting System, ID =Identification, ICC =International Code <br />Council, OPE =Overfill Prevention Equipment <br />Page 1 of 2 <br />