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 10181339 Inspection Date <br /> 04/05/21 <br /> Facility Name SUPER STOP <br /> Facility Address ZIP Code <br /> 2390 N MAIN ST city MANTECA <br /> 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Afforda Test 209-744-0112 <br /> Mailing Address4162nd St Galt CA 95632 <br /> Service Technician Performing Inspection <br /> David Winkler <br /> Contractor/Tank Tester License Number 08-1739 Ex.3/31/2023 <br /> ICC Number 8883059-UT Expiration Date <br /> 1/27/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009853708 11-29-2022 <br /> Emco 43207 Ex. 2/24/23 ATG: VR: B34975 ATG: 2/8/22 INCON 1009853708 11-11-2022 <br /> OPW 104-633 03-13-2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW FLAPPERS <br /> EMCO FLAPPER <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 /> CPIIn�A Tcnhnirinn ginnati irn Date Total # of Pages <br /> V �' 04/05/21 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />