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Appendix IK <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION M Installation ❑ Repair ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 9118123 <br /> Facility Name <br /> RIPON SHELL <br /> Facility Address City ZIP Code <br /> 710 JACK TONE RD 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 /> ContractorlTank Tester License Number <br /> 779267 <br /> ICC Number Expiration Date <br /> 9153991 6125 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS PRO EVR VR-101 #1008533711 9123 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> MANUFACTURE STANDARD DROPTUBES <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. 1 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 I of 2 <br />