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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 TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Pinnacle Fuel Compliance 408=206=9840 <br /> Mailing Address <br /> P . O . Box 32849 <br /> Service Technician Performing Inspection <br /> Aneil Chand <br /> Contractor/Tank Tester License Number <br /> 90= 1262 <br /> ICC 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 3/1 /2023 <br /> OPW Cert # 100208 4/1 /2023 <br /> 4 , INSPECTIONPROCEDURES INFORMATION <br /> InspectionProcedures Used Components Inspected <br /> Veeder Root ATG probe light / horn <br /> 5 . 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. I understand that test procedures shall be made available <br /> upon request by the governing authority. <br /> ��x Date Total # of Pages <br /> Service Technician Signature 4/15/2022 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 />