Laserfiche WebLink
Appendix !X <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION Installation ❑ Repair onth <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 'Y -z<D 2- <br /> Facility <br /> Facility Name <br /> Y <br /> Facility Address City ZIP Code <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> LC SERVICES &11C C r" (559) 444-1730 <br /> Mailing Address <br /> 3887 N VALENTINE <br /> Service Technician Performing Inspection <br /> L "1,4 e / e- <br /> Contractor/Tank Tester License Number <br /> 779267 <br /> ICC Number Expiration Date <br /> 7 12 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS PRO EVR VR-101 <br /> OPw 7 S SL 7 -7 -z1 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> 1 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />