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Appendix IX <br /> O � � m <br /> Underground Storage Tank - O `1 <br /> Over0 <br /> fill Prevention Equiipment Ins e , N <br /> v P coon Report Form � <br /> TYPE OF ACTION E] Installation ❑ Repair cCu <br /> CD0 O <br /> 1. FACILITY INFORMATION ® 36 Month <br /> CERS ID <br /> Cn <br /> ie%eisi, 119 g a Inspection Date n <br /> Facility Name 05126121 • r <br /> Hammer 1-5 Sinclairamm <br /> CD <br /> v <br /> Facility Address City m <br /> 3201 W. Hammer Lane ZIP Code o <br /> I <br /> Stockton95209 �s <br /> can- 12. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection ------ <br /> Phone o' <br /> Alftech Petro, Inc 209-532-7320 <br /> Mailing AddressCD <br /> P.O. Box 4208 Sonora Ca 95370 <br /> Service Technician Performing Inspection <br /> r Isaac Anderson <br /> Contractor/Tank Tester License Number o <br /> Tank Tester 09-1749 �. <br /> }t [CC Number Expiration Date CD <br /> =!�j 8146912 09110122 � <br /> 3. TRAINING AND CERTIFICATIONS <br /> CD <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW#100456 05111122 <br /> C� <br /> 0 <br /> 4. INSPECTION PROCEDURES INFORMATION � <br /> Inspection Procedures Used Components InspectedCD <br /> 87 Master, 87 Syphon, 8 91 Tanks � <br /> PEI RP 12001 0 <br /> Manufacturer <br /> K. <br /> Manufacturer <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, division 3, chapter 16, section 2637.2; that required supporting <br /> documentation is atfached; and al! information contained herein is accurate. 1 understand o 0 <br /> the governing authority. <br /> that test procedures shall be made available upon request by <br /> Date Total # of Pa o <br /> Service Technician Signature 0 126121 2 En -0 <br /> i <br /> N <br /> � W <br /> � CERS = California Environmental Reporting System, ID = Identification, ICC = international Code PQ <br /> N <br /> N Council, OPE = Overfill Prevention Equipment Page <br />