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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 52 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10726990 8.18.2021 <br /> Facility Name <br /> Pilot 1017 <br /> Facility Address City ZIP Code <br /> 345 Roth Rd. Lathrop 95330 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Jones Covey Group Inc. (888) 972-7581 <br /> Mailing Address 9595 Lucas Ranch Rd. #100 Rancho Cucamonga Ca, 91730 <br /> Service Technician Performing Inspection <br /> Justin Zorn <br /> Contractor/Tank Tester License Number <br /> 804431 <br /> ICC Number Expiration Date <br /> ICC - 9157862 2.12.2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW- 0177855 04.02.2023 <br /> Veeder-Root- C28734 06.04.2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Manufacture Guidelines Tank-1 & Tank-2 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 r . Date Total # of Pages <br /> 08.18.2021 20 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />