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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 /> 1/8/2021 <br /> Facility Name <br /> Kwik Sery Lodi <br /> Facility Address City County Zip Code <br /> 420 W Kettleman Lane Lodi San Joaquin ENV <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> BZ Service Station Maintenance 916-371-2380 <br /> Mailing Address <br /> 1041 Triangle Ct., West Sacramento, CA 95826 <br /> Contractor/Tank Tester License Number <br /> 433159 <br /> Service Technician Performing Inspection <br /> Jeff Raven <br /> ICC Number Expiration Date <br /> 9326216 8/31/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW - 0184398 5/13/2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI 1200 Pg.18 4 drop tubes <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> l hereby certify that the OPE was inspected in accordance with California Code of Regulations, title <br /> 23, division 3, chapter 16, section 2637.2; that required supporting documentation is attached;and <br /> al/information contained herein is accurate. /understand that test procedures shall be made <br /> available upon request by the governing authority. <br /> —j-Service T cian Si re Date Total # of Pages <br /> 1/8/2021 <br /> Page 1 of 2 <br />