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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 10181267 <br />Inspection Date <br />7/30/2021 <br />Facility Name CALIF NATIONAL GUARD - STOCKTON AIRPORT <br />Facility Address2000 STINSON ROAD <br />C�ty <br />STOCKTON <br />ZIP Code <br />95206 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Afforda Test <br />Phone <br />209-744-0112 <br />Mailing Address 416 2nd St Galt CA 95632 <br />Service Technician Performing Inspection <br />Zane Nimmo <br />Contractor/Tank Tester License Number 04-1676 Ex.03/31 /2022 <br />ICC Number <br />8883064 -UT <br />Expiration Date <br />5/26/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />EBW , Phil-Tite & EVR Phase 1 10009843708 Ex 11-30-22 <br />OPW 104-632 Ex 3-17-2022 Emco 3206 Ex. 11/14/2022 <br />ATG: VR: A28446 Ex. 10/2/2021 Incon # 1009843708 Ex. 11-30-22 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />REMOVE & INSPECT <br />DROP / FILL TUBES <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 />Cmrvirim Tcrhnir-onn Girinnfiirc <br />Date <br />7/30/2021 <br />Total # of Pages <br />3 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />