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<br />Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br /> <br />Page 1 of 2 <br />TYPE OF ACTION ☐ Installation ☐ Repair ☐ 36 Month <br />1. FACILITY INFORMATION <br /> <br />CERS ID <br /> <br />Inspection Date <br /> <br /> <br />Facility Name <br /> <br /> <br />Facility Address <br /> <br />City <br /> <br />ZIP Code <br /> <br /> <br />2. SERVICE TECHNICIAN INFORMATION <br /> <br />Company Performing the Inspection <br /> <br />Phone <br /> <br /> <br />Mailing Address <br /> <br />Service Technician Performing Inspection <br /> <br />Contractor/Tank Tester License Number <br /> <br /> <br />ICC Number <br /> <br />Expiration Date <br /> <br /> <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications Expiration Date <br /> <br /> <br /> <br /> <br />4. INSPECTION PROCEDURES INFORMATION <br /> <br />Inspection Procedures Used Components Inspected <br /> <br /> <br /> <br /> <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 /> <br />Service Technician Signature Date <br /> <br />Total # of Pages <br /> <br /> <br />10456027 09/27/21 <br />TRACY 76 <br />2420 W GRANTLINE RD TRACY 95376 <br />Afforda Test 209-744-0112 <br />416 2nd St Galt CA 95632 <br />David Winkler <br />08-1739 Ex.3/31/2023 <br />8883059-UT 1/27/2022 <br />FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11/29/22 <br /> Emco #3207 Ex. 2/24/23 ATG: VR: B34975 ATG: 2/8/22 INCON 1009853708 Ex.11/11/2022 <br />OPW 104-633 Ex 3-13-2022 <br />OPW FLAPPERS <br />09/27/21 4