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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION 0 Installation D Repair R 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181431 2/24/2022 <br /> Facility Name <br /> Escalon Mini Mart: <br /> Facility Address City ZIP Code <br /> 1097 E. Yosemite Ave. Escalon 95320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Donlee Pump Company 209-5379396 <br /> Mailing Address <br /> 2825 Railroad Ave. Ceres CA. 95307 <br /> Service Technician Performing Inspection <br /> Gerardo Perez <br /> Contractor/Tank Tester License Number <br /> 432489 <br /> ICC Number Expiration Date <br /> 8962656 <br /> 3. TRAINING AND.CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Emco Wheaton 5131121 <br /> OPW 8126122 <br /> I <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Manufacturer Spec. <br /> 5. .CERTIFICATION,BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> 1 hereby certify that the OPE 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 Signature Date Total # of Pages <br /> CERS California Environmental Reporting System, ID Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> f <br /> Pagel of 2 <br />