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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION 52 Installation ❑ Repair ❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10146285 <br />Inspection Date <br />08/26/2022 <br />Facility Name <br />Costco 658 Tracy <br />Facility Address <br />3250 W Grantline Rd. <br />City <br />Tracy <br />ZIP Code <br />95304 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Jones Covey Group Inc. <br />Phone <br />(888) 972-7581 <br />Mailing Address 9595 Lucas Ranch Road #100, Rancho Cucamonga, CA 91730 <br />Service Technician Performing Inspection <br />Shawn Rodriguez <br />Contractor/Tank Tester License Number <br />804431 A, B HAZ <br />ICC Number <br />8412602 <br />Expiration Date <br />11/13/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root - B47358 <br />02/12/2023 <br />Phil Tite #1021753712 <br />12/04/2022 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />Manufacture Install Instructions <br />T1 -87A, T2-8713, T3 -87C, and T5-91 Defender Series Drop tubes. <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 <br />Date <br />08/26/2022 <br />Total # of Pages <br />47 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />