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p � oD <br /> QJ Q <br /> = <br /> r " C <br /> CDt 060-- <br /> v � O -4v, <br /> W <br /> v _ b w w N <br /> CD ; N CO <br /> CD O <br /> O <br /> CrQ <br /> CD N C7 <br /> m Appendix IX <br /> o' <br /> _ ierground Storage Tank � <br /> C/) OVerinn Preven =quipment� Inspection Report Form <br /> 'TYPE OF ACTION <br /> ❑ Installation ❑ Repair ® 36 Month �' W <br /> FACILITY INFORMATION (D Q <br /> CERS ID `-' <br /> Inspection Date L <br /> v, o <br /> 7-22-21 n <br /> Facility Name o <br /> Safewa <br /> Y Fuel Center � n <br /> Facility Address ZIP Code D <br /> City � <br /> 2808 COUNTRY CLUB BLVD STOCKTON 95204 0 <br /> 2. SERCD <br /> VICE TECHNICIAN INFORMATION <br /> N <br /> Company Performing the Inspection Phone N <br /> Precision Environmental Services Inc 559-553-5420 N <br /> 0 <br /> N <br /> Mailing Address <br /> 1255 N Cherry# 192 Tulare CA. 93274 <br /> Service Technician Performing Inspection <br /> 0 <br /> Adam Ta for cr <br /> Contractor/Tank Tester License Number CD <br /> 1028900 Expiration Date ¢ <br /> ICC Number Nov. 2022 ° <br /> 8143455 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration, Date <br /> OpW UST AND AST 0176488 <br /> c <br /> sPECTION PRO <br /> CEDURES INFORMATION <br /> 4. <br /> 1M_ <br /> N dares Used Components inspected z <br /> insP <br /> action ProCe DROP TUBE OVERFILL VALVES o <br /> CD <br /> rp 1200 <br /> c <br /> CD <br /> Y SERVICE TECHNICIAN CONDUCTING INSPECTION Q. <br /> TIFICATION a opt was inspected in accordance with California Code of <br /> rJ. CER 1 that t 3, chapter 16, section 2637.2;that required supporting x <br /> cert fy 13, division <br /> 1 hereby title � and all information contained herein is accurate. 1 understand <br /> RegulatiQnsI is attached ade available upon request by the governing authority. o m <br /> m "' Date Total#of Pages v n <br /> docu entatc dares shall he <br /> T that test plc n Signature 7-22-21 2 _ <br /> Technicia C 0 <br /> w $ery Reporting System, ID = Identification, ICC = International Code U) o <br /> o Environmental Rep c, <br /> w California E Ui ment <br /> Overfill Prevention q p l Page 1 of 2 4 <br /> Council, OPE ' Cl) <br />