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Appendix IX 22100032.1 <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION FlInstallation ORepair F-136 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10181087 Inspection Date <br /> 7/8/2022 <br /> Facility Name <br /> Arco 2093 <br /> Facility Address City ZIP Code <br /> 3425 Tracy Blvd. Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Gettler-Ryan Inc. 925-551-7444 <br /> Mailing Address <br /> 6805 Sierra Court, Suite G, Dublin, CA 94558 <br /> Service Technician Performing Inspection Robert Jacobs <br /> Contractor/Tank Tester license Number <br /> 220793 <br /> ICC Number Expiration Date <br /> 8819943 <br /> 6/17/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root ATG Tech Cert #C23345 1/15/2023 <br /> OPW UST EVR Phase 1 Tech Cert #0177621 3/30/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Tank Charts/Tape Measure Flapper Valves <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. 1 understand <br /> that fest procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 7/8/2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />