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Appendix 1X <br /> Underground Steerage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION InstallationRepair 36 Month <br /> 1. FACILITY INFORMATION - ---- ---- <br /> CERS ID - - inspection Date - <br /> 10180637 4-29-2022 <br /> Facility Name <br /> Gas and Shop <br /> Facility Address City ZIP Code <br /> 1002 Frontage Road Ripon Ca 95366 <br /> 2, SERVICE TECHNICIAN INFORMATIONT-- <br /> Company Performing the Inspection <br /> Self Serve Petroleum 650 588-3088 <br /> Mailing Address _. <br /> 1045 Airport Blvd. S. San Francisco Ca 94080 <br /> Service Technician Performing Inspection ---- --- <br /> Robert Neimeyer <br /> Contractor/Tank Tester License Number --- <br /> Gen A/ Haz 930666 <br /> ICC Number - -- Expiration Date ---- - <br /> 5248067 10-9-2023 <br /> ' 3. TRAINING AND CERTIFICATIONS --- ----- <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST 3-26-2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Componentsinspected <br /> OPW/ PEI Regular and Super overfill protection shut off valves <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 96, section 2637.2; that required supporting <br /> documentation is attached, and all information contained herein is accurate. l understand <br /> that test procedures spall be ma a available upon request by the governing authority. <br /> Service Te i ion n Date Total # of Pages <br /> 4-29-2022 <br /> CERS = California Environmental Reporting System. ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />