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,,69$ <br /> 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 /> 10180903 12/11/2025 <br /> Facility Name <br /> AA Gasoline Inc <br /> Facility Address City ZIP Code <br /> 440 W. Dr. Martin Luther King Jr Blvd Stockton 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contractors (209)-461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr. Stockton, CA. <br /> Service Technician Performing Inspection <br /> Benjamin Malaspina <br /> Contractor/Tank Tester License Number <br /> 1001331-A <br /> ICC Number Expiration Date <br /> 9519380 06/04/2026 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Phase 1 UST 182799 09/10/2027 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Manufacture Drop Tube OPV <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 at/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 /> '�L 1&1111., 12/11/2025 2 <br /> CERS = California Environmental Reporting System, ID = Identification, [CC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />