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Appendix IX UE020 <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair El 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10207012 2/2/2023 <br /> Facility Name <br /> Pacific Bell Telephone Co. dba AT&T California <br /> Facility Address City ZIP Code <br /> 124 W. Elm St. Lodi 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> TAIT Environmental Services, Inc. (714) 560-8222 <br /> Mailing Address <br /> 11280 Trade Center Dr., Rancho Cordova, CA 95742 <br /> Service Technician Performing Inspection <br /> Christopher Bogan <br /> FContractor/Tank Tester License Number <br /> 588098 <br /> ICC Number Expiration Date <br /> 9901042 01/28/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root-C30413 01/07/2024 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI RP1200 ATG Probe <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 /> r" <br /> 2/2/2023 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />