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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑x 36 Month <br /> �1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181387 1/27/2022 <br /> Facility Name <br /> Ryder Truck Rental <br /> Facility Address City ZIP Code <br /> 3633 Duck Creek Road Stockton 95215 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Balch Petroleum (408) 942-8686 <br /> Mailing Address <br /> 930 Ames Ave. Milpitas, CA 95035 <br /> Service Technician Performing Inspection <br /> Rolando Urbina <br /> Contractor/Tank Tester License Number <br /> 396575 <br /> ICC Number Expiration Date <br /> 8009631-UT 8/19/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root B38055 4/29/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> RP1200 Overfill Prevention Equipment <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 /> W—L -- 1/27/2022 16 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> UN-109 www.unidocs.org Rev,10101/20 Pagel of 2 <br />