Appendix IX Underground Storage Tank
Overfill Prevention Equipment Inspection Report Form TYPE OF ACTION
☐ Installation
☐ Repair
☐ 36 Month
1. FACILITY INFORMATION CERS ID
Inspection Date
Facility Name Facility Address
City
ZIP Code
2. SERVICE TECHNICIAN INFORMATION Company Performing the Inspection
Phone
Mailing Address Service Technician Performing Inspection Contractor/Tank Tester License Number ICC Number
Expiration Date
3. TRAINING AND CERTIFICATIONS Manufacturer and Test Equipment Training Certifications
Expiration Date
4. INSPECTION PROCEDURES INFORMATION Inspection Procedures Used Components Inspected
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION I hereby certify that the OPE was inspected in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting documentation is attached; and all information contained herein is accurate. I understand that test procedures shall be made available upon request by the governing authority. Service Technician Signature
Date
Total # of Pages
CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, OPE = Overfill Prevention Equipment Page 1 of 2