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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 10180541 <br />Inspection Date 1/7/21 <br />Facility NameJOES TRAVEL PLAZA <br />Facility Address 15600 S HARLAN ROAD <br />City LATH ROP <br />ZIP Code <br />95330 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Affords Test <br />Phone <br />209-744-0112 <br />Mailing Address 416 2nd St Galt CA 95632 <br />Service Technician Performing Inspection Edward Stearns <br />Contractor/Tank Tester License Number 14-1760 Ex. 09/30/2020 <br />ICC Number <br />8883080 -UT <br />Expiration Date <br />11/9/20 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11/29/2020 <br />Emco 3205 Ex. 11/16/2020 ATG: VR A31048 Ex.8/9/19 Incon 1009893708 11/30/2020 <br />OPW 104-635 Ex 3-14-2020 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />REMOVED DROP TUBES <br />OVERFILL VALVES <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 />Ccrvir-c Tcr-hnirrinn Cinnnfi irc <br />Date <br />1/7/21 <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 />