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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION E Installation 17 Repair ® 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10181455 <br />Inspection Date <br />08/16/2022 <br />Facility Name , <br />Unifi Grocers 'DIC Pr VGi Ic, <br />Facility Address <br />1990 Piccoli Rd <br />City <br />Stockton <br />ZIP Code <br />95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Elite IV Contractors <br />Phone <br />(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 />Elite IV Contractors 1001331 <br />ICC Number <br />4593 <br />Expiration Date <br />04/27/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW 0192139 VST Phase 1 <br />05/19/2023 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />Manufacture Standards <br />Diesel droptube 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�,� d//ivn n`; cc a r 96, section 2637.2; that required supporting <br />documentation is attached; and all info ation contained herein is accurate. I understand <br />that test proced es shall be made av Mable upon request by the governing authority. <br />Service Tech ian Egna ure <br />Date <br />08/16/2022 <br />Total # of Pages <br />2 <br />CERS = Ca nvironmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />