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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 2 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10180819 Inspection Date <br /> 06/03/24 <br /> Facility Name MY MINI MART <br /> Facility Address 1756 N WILSON WAY City STOCKTON ZIP Code <br /> 95205 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the InspectionNORCALTANK TESTINH Phone209-744-0112 <br /> Mailing Address 877 BATEMAN WAY CA 95632 <br /> Service Technician Performing Inspection David Winkler <br /> Contractor/Tank Tester License Number 08.1739 Ex.2/28/26 <br /> ICC Number Expiration Date <br /> 8883059-UT 1/27/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW 104-633 3/10/26 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW FLAPPERS <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 /> Conrir•c T=rrhnininn Cirrnn+i mn Date Total # of Pages <br /> Iw 06/03/24 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />