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 /> 10181399 10/6/21 <br /> Facility Name <br /> Grant Line Shell <br /> Facility Address City ZIP Code <br /> 2375 WestGrant Line Rd. Tracy 95376 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Alltech Petro Inc. 209-532-7320 <br /> Mailing Address <br /> P.O. Box 4208 Sonora Ca 95370 <br /> Service Technician Performing Inspection <br /> Chad White <br /> Contractor/Tank Tester License Number <br /> Ca632541/09-1747 <br /> ICC Number Expiration Date <br /> 8152115 2/13/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS Stage I Systems #1015593710 5/30/2022 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI RP 1200-17 8.2.1.6 Shut off 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 /> Service Technician Signature Date Total # of Pages <br /> 10/6/21 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />