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COMPLIANCE INFO_2021
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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DR MARTIN LUTHER KING JR
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2300 - Underground Storage Tank Program
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PR0231058
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COMPLIANCE INFO_2021
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Entry Properties
Last modified
6/16/2022 8:00:43 AM
Creation date
5/26/2021 8:50:00 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2300 - Underground Storage Tank Program
File Section
COMPLIANCE INFO
FileName_PostFix
2021
RECORD_ID
PR0231058
PE
2361
FACILITY_ID
FA0003738
FACILITY_NAME
CHARTER WAY SHELL*
STREET_NUMBER
620
Direction
W
STREET_NAME
DR MARTIN LUTHER KING JR
STREET_TYPE
BLVD
City
Stockton
Zip
95206
APN
16504007
CURRENT_STATUS
01
SITE_LOCATION
620 W DR MARTIN LUTHER KING JR BLVD
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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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 10181363 Inspection Date <br /> 6/18/2021 <br /> Facility Name CHARTER WAY SHELL <br /> Facility Address 620 W. (CHARTER WAY) Dr. Martin Luther King City ZIP Code <br /> STOCKTON 95206 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> AFFORDA TEST 209-744-0112 <br /> Mailing Address 416 2ND STREET GALT, CA 95632 <br /> Service Technician Performing Inspection ZAN E N I M MO <br /> Contractor/Tank Tester License Number 04-1676 Ex.03/31 /2022 <br /> ICC Number Expiration Date <br /> 8883064-UT 5/26/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> EBW , Phil-Tite & EVR Phase 1 10009843708 Ex 11-30-22 <br /> OPW 104-632 Ex 3-17-2022 Emco 3206 Ex. 11/14/2022 <br /> ATG: VR: A28446 Ex. 10/2/2021 Incon # 1009843708 Ex.11-30-22 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> REMOVE & INSPECT DROP / FILL 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 /> Cmrvirim Tcrhnir-onn Girinnfiim Date Total # of Pages <br /> 6/18/2021 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />
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