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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 />69 <br />CERS ID <br />10180903 <br />Inspection Date <br />12/11/2025 <br />Facility Name <br />AA Gasoline Inc <br />Facility Address <br />440 W. Dr. Martin Luther King Jr Blvd <br />City <br />Stockton <br />ZIP Code <br />95206 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Elite IV Contractors <br />Phone <br />(209)-461-6337 <br />Mailing Address <br />2535 Wigwam Dr. Stockton, CA. <br />Service Technician Performing Inspection <br />Benjamin Malaspina <br />Contractor/Tank Tester License Number <br />1001331-A <br />ICC Number <br />9519380 <br />Expiration Date <br />06104/2026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW Phase 1 UST 182799 <br />09/10/2027 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />Manufacture <br />Drop Tube OPV <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 96, section 2637.2; that required supporting <br />documentation is attached; and at/ 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 />'�L 1&*., <br />Date <br />12/11/2025 <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 />