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 /> 7-22-21 <br /> Facility Name <br /> Safeway Fuel Center <br /> Facility Address City ZIP Code <br /> 2802 COUNTRY CLUB BLVD STOCKTON 95204 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Precision Environmental Services Inc 559-553-5420 <br /> Mailing Address <br /> 1255 N Cherry # 192 Tulare CA. 93274 <br /> Service Technician Performing Inspection <br /> Adam Ta for <br /> Contractor/Tank Tester License Number <br /> 1028900 <br /> ICC Number Expiration Date <br /> 8143455 Nov. 2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW UST AND AST 0176488 7-18-23 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> rp 1200 DROP TUBE OVERFILL VALVES <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 /> ServicTechnician Signature Date Total # of Pages <br /> 7-22-21 2 <br /> CERS = California Environm al Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />