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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10180661 Inspection Date <br /> 12-15-2021 <br /> Facility Name ONE STOP <br /> Facility Address 1151 LOU ISE AVE pity ZIP Code <br /> MANTECA <br /> 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Afforda Test 209-744-0112 <br /> Mailing Address4162nd St Galt CA 95632 <br /> Service Technician Performing Inspection Felix Ramirez <br /> Contractor/Tank Tester License Number 08-1740 Ex. 05/31 /2023 <br /> ICC Number 8883072-UT Expiration Date <br /> 11/6/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FF- FF- EBW , Phil-Tite & EVR Phase 1 1009883708 EX 12/28/22 <br /> Emco 3147 Ex. 02/24/23 VR: B34976 ATG: 7/7/22 Incon 1009883708 Ex 12/11/22 <br /> OPW 104-634 Ex 3/17/22 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW / EMCO FLAPPER <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 Fe P)?ao <br /> r �� <br /> , Date Total # of Pages <br /> 12-15-2021 5 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />