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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 Inspection Date <br /> 10181511 09/10/2024 <br /> Facility Name <br /> Boyett Petroleum #98 / Kwik Sery <br /> Facility Address City ZIP Code <br /> 2501 Jackson Ave. Escalon 95320 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> CGRS, Inc. (916) 991-1100 <br /> Mailing Address <br /> 5444 Dry Creek Road• Sacramento CA. 95838 <br /> Service Technician Performing Inspection <br /> Leo Ran el <br /> Contractor/Tank Tester License Number <br /> CSLB#803616 <br /> ICC Number Expiration Date <br /> 8711887 07/07/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST EVR Phase 1 Cert.# 0167932 02/19/2024 <br /> F.F.S. EVR Phase 1 Systems — VR-101 Cert.#1004793709 04/27/2023 <br /> Universal 47-20 Waste Oil Cert. #122224-2 01/24/2026 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> RP-1200 / Manufacture's IOM Overfill Valves / 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 /> Service Technician Signature Date Total # of Pages <br /> Leo Rangel 09/10/2024 8 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />