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I Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑installation ❑Repair X 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10184725 4/15/2022 <br /> Facility Name <br /> Chevron <br /> Facility Address City ZIP Code <br /> 2615 Grant Line Road Tracy 95304 <br /> 2. SERVICE TECHNICIANINFORMATION <br /> Company Performing the Inspection Phone <br /> Pinnacle Fuel Compliance 40$-20fi-9840 <br /> Mailing Address <br /> P.D. Box 32849 <br /> Service Technician Performing Inspection <br /> Aneil Chand <br /> Contractor/Tank Tester License Number <br /> 90-1262 <br /> [CC Number Expiration Date <br /> 8455316 5/27/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root Cert# A21783 3/12/2024 <br /> Franklin Fueling System Cert#1001943708 311/2023 <br /> OPW Cert#100208 4/1/2023 <br /> 4. 1NSPECTIONPROCEDURES INFORMATION <br /> InspectionProcedures Used Components Inspected <br /> Veeder Root ATG probe light 1 horn <br /> S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> 1 hereby certify that the OPE was inspected in accordance with California Code of Regulations, title <br /> 23, division 3, chapter 16, section 2637.2;that required supporting documentation is attached;and all <br /> information contained herein Is accurate. 1 understand that test procedures shall be made available <br /> upon request by the governing authority. <br /> Date Total#of Pages <br /> Service Technician Signature = _ 4/1512022 12 <br /> 6. OVERFILL PREVENTION EQUIPMENT DETAILS <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />