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Appendix IX 21202049 <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />Inspection Procedures Used <br />Tank Chart/Tape Measure <br />D Installation JRepair Month <br />[1.FACILITY INFORMATION <br />CERS ID Inspection Date <br />10181235 7/6/2021 <br />Facility Name <br />Arco 5450 <br />Facility Address City ZIP Code <br />1517 W.Fremont Stockton 95203 <br />2.SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection Phone <br />Gettler-Ryan Inc.925-551-7444 <br />Mailing Address <br />6805 Sierra Court,Suite G,Dublin,CA 94568 <br />Service Technician Performing Inspection <br />Damell Smith <br />Contractor/Tank Tester License Number <br />220793 <br />ICC Number Expiration Date <br />‘8709494 11/23/2021 <br />3.TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br />Veerder Root Tech Cert #B48857 3/23/2022 <br />4.INSPECTION PROCEDURES INFORMATION <br />Components Inspected <br />Veeder Root TLM Probes <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 -Date Total #of Pages <br />_________________________7.—tZ—-—7/6/2021 <br />2 <br />CERS =California Environmental Reporting System,ID =Identification,ICC =International Code <br />Council,OPE =Overfill Prevention Equipment <br />TYPE OF ACTION <br />Page 1 of2