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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION Installation Test Repair Test 36 Month Test <br />1. FACILITY INFORMATION <br /> CERS ID <br /> 10851091 <br /> Inspection Date <br /> 10/30/2020 <br /> Facility Name <br /> 7-Eleven 38877 <br /> Facility Address <br /> 1515 E Main St <br /> City <br /> Stockton <br /> Zip Code <br /> 95205 <br />2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection <br /> Tanknology, Inc. <br /> Phone <br /> (800) 800-4633 <br /> Mailing Address <br /> 11000 N. MoPac Suite 500, Austin, Tx. 78759 <br /> Service Technician Performing Inspection <br /> Michael Deatherage <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number <br /> 8819901 <br /> Expiration Date <br /> 11/8/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Veeder Root-Vapor Products C23389 04/12/2022 <br />Tanknology Certification-Level III Spill Container Testing Certification Exam 142040 03/21/2021 <br />- <br />4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedure Used Components Inspected <br /> veeder root guidelines ATG Probes/HLA <br /> <br /> <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 Signature <br /> <br /> Date <br />10/30/2020 <br /> Total # of Pages <br /> 2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment