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Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION �/❑ Installation ❑ Repair �/❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10186687 <br />Inspection Date <br />8/18/23 <br />Facility Name <br />A Gas - Food Mart <br />Facility Address <br />2115 W Yosemite <br />City <br />Manteca <br />ZIP Code <br />95337 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Service Station Systems <br />Phone <br />(408) 971-2445 <br />Mailing Address <br />680 Quinn Ave San Jose CA 95112 <br />Service Technician Performing Inspection <br />Samantha McMahan <br />Contractor/Tank Tester License Number <br />485184 <br />ICC Number <br />8650093 <br />Expiration Date <br />1/24/25 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW # 0182767 <br />1/6/24 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />OPW <br />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 />8/18/23 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />