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 t <br /> Inspection Dae <br /> 101 $1513 9/23/2021 <br /> Facility Name VAN DE POL RIPON CFN <br /> Facility Address <br /> 816 S FRONTAGE RD CI�RIPON zrP�Code. <br /> 96366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the inspection Phone <br /> Afforda Test 209-744-0112 <br /> Mailing Address <br /> 416 2*nd' St Galt CA 95632 <br /> Service Technician Performing Inspection Edward Stearns <br /> Contractor/Tank Tester License Number 14-1760 EX. 09/30/2020 <br /> ICC Number t <br /> Expiration Dae <br /> $883080-UT 11/6i2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FF- EBW, Phil-Tito &EVR Phase 1 1009893708 Ex 11/28/2022 <br /> Emco 3205 Ex.02/24/2023 ATG:VR A31048 Ex.7/31/2021 Incon 1009893708 3/1/2023 <br /> OPW 104-635 Ex 3-12-2022 <br /> 4 INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> MANUFACTURER OVERFILL VALVE <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 /> !tiAnArP Torinnirimn ginn=fi mo Date Total #of Pages <br /> 9/23/2021 5g <br /> CERS = California Environmental Reporting.System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />