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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 /> 10141507 2021 -08- 05 <br /> Facility Name <br /> Manteca CO <br /> Facility Address City ZIP Code <br /> 430 W. Center Street TManteca 95336 <br /> 2 . SERVICE TECHNICIAN INFORMATION ' <br /> Company Performing the Inspection Phone <br /> SunWest Engineering Constructors , Inc ( 888 ) 58 &8737 <br /> Mailing Address <br /> 4780 Cheyenne Way , Chino CA 91710 <br /> Service Technician Performing Inspection <br /> Ruben Becerra Jr . <br /> Contractor/Tank Tester License Number <br /> 703190 <br /> ICC Number Expiration Date <br /> 5302139 01 - 05 -2023 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> EMCO Phase II EVR 2022/07/ 10 <br /> 4. f INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> manufacturer guidelines overfill prevention valve <br /> manufacturer guidelines ATG <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 Date Total # of Pages <br /> 08 -05-2021 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council , OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />