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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION El Installation r] Repair 17 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10448341 06/16/2022 <br /> Facility Name <br /> Love's Travel Stop#538 <br /> Facility Address City ZIP Code <br /> 15250 N. Thorton Rd. Lodi 95242 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contractors (209)461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton CA 95205 <br /> Service Technician Performing Inspection <br /> Adrian Rodriguez <br /> Contractor/Tank Tester License Number <br /> 1001331 <br /> ICC Number Expiration Date <br /> 9914593 04/27/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW EVR UST 0192139 05/19/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Visual/Tape Measure 87, 91 and Diesel drop tubes Overfill Prevention <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, divis , 16, section 2637.2; that required supporting <br /> documentation is a ched; and all info r ation contained herein is accurate. 1 understand <br /> that test proce res shall be made a ilable upon request by the governing authority. <br /> ServiceTec ician Si�natu Date Total # of Pages <br /> 06/17/2022 2 <br /> CER = Cal' aEnvironmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />