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F Jj <br /> Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair p 36 Month <br /> ()F ACrio El. FACILITY INFORMATION <br /> CILt �(3ERS ID Inspection Date <br /> L 101822511 02-12-2024 <br /> Cacility Name <br /> ARCH ARCO AMPM <br /> V-- <br /> Facility Address =CiSTO( <br /> AMP 4855 MOUTH HUGHWrAY ne -----------�:] <br /> ;KTON ZIP Code <br /> Vvy 91dres 9 C SERVICE TECHNICIAN INFORMATION <br /> V= <br /> �mpany Performing the Inspection T�h��� <br /> t' TEC1 ECO-CHEK. COMPLINCE,INC. 112 <br /> er m Mailing Address <br /> t P.O. BOX 1394 LAFA.YETTE, CA 94.549 <br /> 'ss Service Technician Performing Inspection <br /> 7a/t C Felix Ramirez <br /> ciao i� ContractorlTank Tester License Number <br /> 08-1740 Ex. 05/31/2026 <br /> res <br /> ICC I\lumber Expiration Date <br /> 31i- 8883072--UT 11/1 /2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> i C FF-FF- EBW, Phil-Tite & EVR Phase 1 1009883708 EX 12/28/24 <br /> 12/28/2024 <br /> es Emco 3147 Ex.02/24/235 VR:B34976 ATG:7/08/2024 Incon 1009883708 Ex 12/11/24 <br /> OPW 104-634 Ex 3/10/2024 03/10/2024 <br /> 4. INSI�ECTION PROCEDUR RMA <br /> ES INFOTION <br /> Inspech'on Procedures Used Components Inspected <br /> OPW FLAPPER VALVES <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> /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 /> JepRa�,yru�,, Date Total # of Pages <br /> 02-12-2024 2 <br /> CERS = California Environmental Reporting System, IID = Identification, ICC <br /> Council, OPE: = Overfill Prevention Equipment = International Code <br /> Page 1 of 2 <br />