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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 10182157 Inspection Date <br /> 01/16/24 <br /> Facility Name TIGER 76 <br /> Facility Address 5777 S FRENCH CAMP City ZIP Code <br /> FRENCH CAMP 95321 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Affords Test 209-744-0112 <br /> Mailing Address416 2nd St Galt CA 95632 <br /> Service Technician Performing Inspection David Winkler <br /> Contractor/Tank Tester License Number <br /> 08_1739 Ex.2/28/26 <br /> ICC Number Expiration Date <br /> 8883059-UT 01/30/24 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11/29/24 <br /> Emco #3207 Ex. 2/24/25 ATG: VR: B34975 ATG: 2/8/24 INCON 1009853708 Ex.11/11/24 <br /> O PW 104-633 Ex 3-13-24 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW FLAPPERS <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 /> Ccrvir-c Tcr-hnirrinn Cinnnfi irc Date Total # of Pages <br /> w01/16/24 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />