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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION 0 Installation © Repair © 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10180967 <br />Inspection Date <br />7/22/2021 <br />Facility Name <br />Quik Stop #144 <br />Facility Address <br />7272 WEST LANE <br />City <br />STOCKTON <br />ZIP Code <br />95210 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Walton Engineering, Inc. <br />Phone <br />916-373-1166 <br />Mailing Address <br />P.O. Box 1025, West Sacramento, CA 95691 <br />Service Technician Performing Inspection <br />MAXWELL HINES <br />Contractor/Tank Tester License Number <br />617238 <br />ICC Number <br />8750053 <br />Expiration Date <br />10/24/2021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />VEEDER ROOT <br />3/3/2022 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />VISUAL <br />ALL GRADE DROP 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 />Service Technician Signature <br />Y� �-� <br />Date <br />7/22/2021 <br />Total # of Pages <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />