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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 Inspection Date <br /> 9/18/23 <br /> Facility Name <br /> RIPON SHELL <br /> Facility Address City ZIP Code <br /> 710 JACK TONE RD t RIPON <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> LC SERVICES (559) 444-1730 <br /> Mailing Address <br /> 3887 N VALENTINE <br /> Service Technician Performing Inspection <br /> JESUS ALVAREZ <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number Expiration Date <br /> 9153991 6/25 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS PRO EVR VR-101 #1008533711 9/23 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> MANUFACTURE STANDARD DROPTUBES <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> 1 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 /> RS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />