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Received by EHD via email from Appendix IX <br /> Glenn Paredes on: <br /> 9/27/2022 Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION © Installation © Repair 0 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10902574 7/13/2022 <br /> Facility Name <br /> Safeway#5816 <br /> Facility Address City ZIP Code <br /> 19533 South Mountain House Parkway Mountain House 95391 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> B&T Service Station Contractors 805-929-8944 <br /> Mailing Address <br /> 630 South Frontage Road Nipomo <br /> Service Technician Performing Inspection <br /> Les Henderson <br /> Contractor/Tank Tester License Number <br /> 902034 <br /> ICC Number Expiration Date <br /> 5250415 03/27/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW - 1193931 July 25, 2024 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> RP1200 <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 /> 71 7/13/2022 8 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />