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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION Z Installation ❑ Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10180633 218122 <br /> Facility Name <br /> Short Stop Food Mart <br /> Facility Address City ZIP Code <br /> 20 W. Turner Rd. Lodi 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contractors (209)461-6337 <br /> Mailing Address <br /> 2535 Wi man Dr. Stockton CA 95205 <br /> Service Technician Performing Inspection <br /> Christopher Adams <br /> Contractor/Tank Tester License Number <br /> 1001331 A-HAZ <br /> ICC Number Expiration Date <br /> 8230218 918123 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling EW-R- Phase 1 1014863710 7120123 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Franklin Fueling EBW Overfill Valve <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 test procedures shall be made available upon request by the governing authority. <br /> See Tec ci� gnature Date Total # of Pages <br /> 2!8122 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />