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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection <br />TYPE OF ACTION ❑ Installation <br />❑ Repair <br />Report Form <br />® 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181511 <br />Inspection Date <br />7/20/2021 <br />Facility Name <br />Kwik Sery Escalon <br />Facility Address <br />2501 Jackson Ave <br />City <br />Escalon <br />County <br />San Joaquin EMD <br />Zip Code <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />BZ Service Station Maintenance <br />Phone <br />916-371-2380 <br />Mailing Address <br />1041 Triangle Ct., West Sacramento, CA 95826 <br />Contractor/ Tank Tester License Number <br />433159 <br />Service Technician Performing Inspection <br />Rick Smith <br />ICC Number <br />9940359 <br />piration Date <br />F3/11 /2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FFS Philtite - 1001813701 <br />3/12/2023 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />PEI 1200 Pg. 18 <br />3 drop tubes <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br />/ hereby certify that the OPE was inspected in accordance with California Code of Regulations, title <br />23, division 3, chapter 16, section 2637.2; that required supporting documentation is attached; and <br />a// information contained herein is accurate. / understand that test procedures shall be made <br />avai/ab/e upon request by the governing authority. <br />Service Technician Signature <br />Date <br />7/20/2021 <br />Total # of Pages <br />Page 1 of 2 <br />