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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION Installation Test F- Repair Test 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181653 1/14/2021 <br /> Facility Name <br /> CHEVRON 201761 <br /> Facility Address City Zip Code <br /> 1103 S. MAIN ST. PERMIT NUMB. N-3315 MANTECA 95337 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Tanknology, Inc. (800) 800-4633 <br /> Mailing Address <br /> 11000 N. MoPac Suite 500, Austin, Tx. 78759 <br /> Service Technician Performing Inspection <br /> Brent Bowen <br /> Contractor/Tank Tester License Number <br /> Class A General Engineering 743160 <br /> ICC Number Expiration Date <br /> 8211862 6/17/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> CA-Tightness Testing 14-1759 08/31/2023 <br /> OPW-EVR Phase 1 100255 01/05/2022 <br /> ICC-CA UST Service Technician 8211862 06/17/2021 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedure Used Components Inspected <br /> Opw 71 so drop tubes Flappers shutoff valves <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> /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 Date Total #of Pages <br /> 1/14/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br />