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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair <br />❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID 10180913 <br />Inspection Date <br />08-11-2021 <br />Facility NameERNIE'S GENERAL STORE <br />Facility Address 4407 E WATERLOO RD <br />CItySTOCKTON <br />ZIP Code <br />95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />AFFORDA TEST <br />Phone <br />209-744-0112 <br />Mailing Address 416 2ND STREET GALT, CA 95632 <br />Service Technician Performing Inspection FELIX RAMIREZ <br />Contractor/Tank Tester License Number 08.1740 Ex. 05/31/2023 <br />ICC Number <br />8883072 -UT <br />Expiration Date <br />11/6/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FF- FF- EBW , PhikTite & EVR Phase 1 1009883708 EX 12/28/22 <br />Emco 3147 Ex. 02/24/23 VR: B34976 ATG: 7/7/22 Incon 1009883708 Ex 12/11/22 <br />OPW 104-634 Ex 3/17/22 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />OPW <br />TEST FLAPPER <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. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature F 4 a� <br />�iG� <br />Date <br />0& 11-2021 <br />Total # of Pages <br />6 <br />CERS =California Environmental Reporting System, ID =Identification, ICC =International Code <br />Council, OPE =Overfill Prevention Equipment <br />Page 1 of 2 <br />