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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report For <br />TYPE OF ACTION Installation Repair Lg 36 Month <br />CAPII 1TV tKir:0RMATION1 <br />CERS ID <br />Inspection Date <br />Facility Name <br />escaloyn <br />Facility Address City ZIP Code <br />2' SERVICE `CECHNICIAN INFORMATION , <br />Company Performing the Inspection Phone <br />cbn le?— rl uw-� <br />Mailing Address <br />gg 5S o d Avt , C, f A 95301 <br />Service Technician Performing Inspection <br />Contractor/Tank Tester License Number <br />�a0.1T5 Ci <br />ICC Number Expiration Date <br />6rd�G- <br />3 TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />/d0 Z2- <br />- <br />1 Z6� •`a -4 0 <br />10-4 6 � <br />4. INSPECTION:PROCEDURES INFORMATION <br />Inspection Procedures Used Components Inspected <br />5..CERTIFICATION BY SERVICE 'TECHNICIAN CONDUCTING INSPECTION' <br />1 hereby certify that the ®PE was inspected in accordance with California Code of <br />Regulations, title 23, division 3, chapter 96, section 2637.2; that required supporting <br />documentation is attached, and all information contained herein is accurate. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician SI nature Date Total # of Pages <br />CERS = California Environmental Reporting System, ID a Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />