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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 />10180605 <br />Inspection Date <br />4/2312024 <br />Facility Name FLAG CITY CHEVRON <br />Facility AddressCity <br />6421 CAPITOL AVE <br />L O D I <br />ZIP Code <br />95242 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Eco - Chek <br />Phone <br />888-500-CHEK <br />Mailing Address 3249 Mt. Diablo Ct. Lafayette , CA 94549 <br />Service Technician Performing Inspection Zane Nimmo <br />Contractor/Tank Tester License Number 04-1676 EX. 4/30/2025 <br />ICC Number <br />8883064 -UT <br />Expiration Date <br />5/27/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />EBW , PhikTite & EVR Phase 1 10009843708 - <br />12/5/2024 <br />OPW 104-632 - Ex 3/10/2026 / Emco 3206 - <br />6/29/2025 <br />ATG: VR: A28446 Ex. 10/9/2025 / Incon # 1009843708 - <br />12/5/2024 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />REMOVE & INSPECT <br />Components Inspected <br />DROP / FILL TUBES <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. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />Ceniica Tprhniria-n. ginnAture _. - - -. - - <br />}_ <br />Date <br />4/23/ 2024 <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 />