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Appendix IX <br />Underground Storage Tank <br />Overfill Prevonti®n Equipment Inspection Report Foran <br />TYPE OF ACTION ® Installation El Repair ® 36 Month <br />1, FACILITY INFORMATION <br />CERS ID <br />10181431 <br />Inspection Date <br />11/17/2021 <br />Facility Name <br />Statewide Petroleum . <br />Facility Address <br />1700 E. Yosemite Ave. <br />City <br />Manteca <br />ZIP Code <br />94566 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Donlee Pump Company <br />Phone <br />(209) 537-9396 <br />Mailing Address <br />2825 Railroad Ave. Ceres CA. 96307 <br />Service Technician Performing Inspection <br />Mario Romero <br />Contractor/Tank Tester License Number <br />432089 <br />ICC Number <br />8034353 <br />Expiration Date <br />1016122 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Opvy <br />5114122 <br />4. 'INSPECTION PROCEDURES INFORMATION; <br />Inspection Procedures Used <br />Components Inspected <br />C (Ae <br />be:5 Pr q 1 <br />5. 'CERTIFICATION BY SERVICE TECHNIOIAN.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 attached, and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technic' n Signature <br />Date <br />_d <br />Total # of Pages <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />