Laserfiche WebLink
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 /> 10184365 09/08/21 <br /> Facility Name <br /> Gas 4 Less <br /> Facility Address City ZIP Code <br /> 3408 Manthey Rd . Stockton 95206 <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Service Station Systems , Inc. (408) 971 -2445 <br /> Mailing Address <br /> 680 Quinn Ave. San Jose , CA 95112 <br /> Service Technician Performing Inspection <br /> Kristopher Bell <br /> Contractor/Tank Tester License Number <br /> 485184 <br /> ICC Number Expiration Date <br /> 8833000 07/28/2022 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Franklin Fueling # 1004933708 09/14/2021 <br /> Veeder Root TLS - 3XX # B33709 03/05/2023 <br /> OPW # 1192275 06/03/2023 <br /> 4 . INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW Ball Floats / Probes <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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> tA 4 09/08/2021 2 <br /> CERS = California Environmental Reporting System , ID = Identification , ICC = International Code <br /> Council , OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />