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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair p 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID 10181355 Inspection Date <br /> 03-05-2024 <br /> Facility NameTIWANAGAS <br /> Facility Address 1210 HAMMER LANE city STOCKTON ZIP Code <br /> 95824 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> ECO CHEK COMPLAINCE INC 888-500-CHEK <br /> Mailing Address P.O. BOX 1394 LAFAYETTE CA 95459 <br /> Service Technician Performing Inspection Felix Ramirez <br /> Contractor/Tank Tester License Number 08.1740 Ex. 03/31 /2026 <br /> ICC Number Expiration Date <br /> 8883072-UT 11/10/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FF- FF- EBW , Phil-Tite & EVR Phase 1 1009883708 EX 11-29-24 <br /> Emco 3147 Ex. 11-16-24 VR: B34976 ATG: 7/05/24 Incon 1009883708 Ex 11-30-24 <br /> OPW 104-634 Ex 3-14-2024 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> FF DEFENDERS REMOVE 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 /> a+i gra Date Total # of Pages <br /> 03-05-2024 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />