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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 10767814 Inspection Date <br /> 1/13/2025 <br /> Facility Name TO KAY KW I K S E RV <br /> Facility Address City <br /> W. KETTLEMAN LANE City ZIP Code <br /> L O D 1 <br /> 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> ECO - Chek 888-500-CHEK <br /> Mailing Address 3249 Mt. Diablo Ct. Lafayette , CA 94549 <br /> Service Technician Performing Inspection <br /> Zane Nimmo <br /> Contractor/Tank Tester License Number 04-1676 EX. 4/30/2025 <br /> ICC Number Expiration Date <br /> 8883064-UT 5/27/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> EBW , Phil-Tite & EVR Phase 1 10009843708 - 12/5/2024 <br /> OPW 104-632 - Ex 3/10/2026 / Emco 3206 - 6/29/2025 <br /> ATG: VR: A28446 Ex. 10/9/2025 / Incon # 1009843708 - 12/5/2024 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> REMOVE & INSPECT DROP / FILL 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 /> ri - <br /> lino Tcrrhnininn Cinnn i irc Date Total # of Pages <br /> 1/13/2025 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />