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Appendix IX <br />Underground Storage Tank <br />Overrill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑✓ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181447 <br />Inspection Date <br />06/07/21 <br />Facility Name <br />Speedway 4681 <br />Facility Address <br />2500 W Lodi <br />City <br />Lodi <br />ZIP Code <br />95242 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Service Station Systems, Inc. <br />Phone <br />(408) 971-2445 <br />Mailing Address <br />680 Quinn Ave. San Jose, CA 95112 <br />Service Technician Performing Inspection <br />Kristopher Bell <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />8833000 <br />Expiration Date <br />07/28/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Franklin Fueling # 1004933708 <br />09/14/2021 <br />Veeder Root TLS - 3XX # B33709 <br />03/05/2023 <br />OPW # 902968 <br />06/03/2023 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />PEI 1200 <br />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 />��;L4.2e <br />Date <br />06/07/2021 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />