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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 /> 10902574 7/15125 <br /> Facility Name <br /> Safeway 5816 <br /> Facility Address City ZIP Code <br /> 19533 S Mountain House Pkwy Mountain House 95391 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Service Station Systems (408)971-2445 <br /> Mailing Address <br /> 680 Quinn Ave San Jose CA 95112 <br /> Service Technician Performing Inspection <br /> Kristopher Bell <br /> Contractor/Tank Tester License Number <br /> 485184 <br /> ICC Number Expiration Date <br /> 8833000 118127 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling # 1004933708 6111126 <br /> OPW# 1192275 4/28/27 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW 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 Sign t Date Total # of Pages <br /> 7/15/25 3 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />