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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 91 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10181431 Inspection Date <br /> 8-16-2022 <br /> Facility Name <br /> Manteca Valero <br /> Facility Address City ZIP Code <br /> 1700 E. Yosemite Ave. Manteca 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> TANK-TIGHT SYSTEMS, INC (916)378-4167 <br /> Mailing Address <br /> 1729 Crystal Ct., Olivehurst, CA 95961 <br /> Service Technician Performing Inspection <br /> BRIAN ROTH <br /> Contractor/Tank Tester License Number <br /> 1066914 <br /> ICC Number Expiration Date <br /> 8834817 11/14/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Phase 1 UST Enhanced Vapor Recovery 10/21/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Tank Charts and Measurment 87,91 Droptubes <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 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 Technician Signature Date Total # of Pages <br /> /§e� 8-16-2022 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />