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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report" Form <br /> TYPE OF ACTION E Installation ® Repair 97 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10181335 01/21/2022 <br /> Facility Name <br /> Chevron#94275 <br /> Facility Address City ZIP Code <br /> 2905 West Benjamin Holt Stockton 95207 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Wayne Perry Inc. 916-646-9680 <br /> Mailing Address <br /> 30 Main Ave Suite 5 Sacramento, CA 95838 <br /> Service Technician Performing Inspection <br /> Dean Walker <br /> Contractor/Tank Tester License Number <br /> 300345 <br /> ]CC Number Expiration Date <br /> 9280239 02-19•-2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 101134 03-19-2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Measurement&Tank Charts Drop Tubes <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 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 /> 01-21-2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Pagel of 2 <br />