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IX <br /> Undc;rgrotmd Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ® Repair 177136 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10184191 11/17/2021 <br /> Facility Name <br /> A&A Gas & Food <br /> Facility Address City County Zip Code <br /> 1330 E Yosemite Ave Manteca San Joaquin EMD <br /> 2. SERVICE TECHNICIAN INFORMATION Phone <br /> Company Performing the Inspection 916-371-2380 <br /> BZ Service Station Maintenance <br /> Mailing Address <br /> 1041 Triangle Ct.,West Sacramento, CA 95826 <br /> Contractor!Tank Tester License Number <br /> 433159 <br /> ` Service Technician Performing Inspection <br /> Rhome Desbiens <br /> 1ICC Number Expiration Date <br /> 8245558 12/10/2022 <br /> 3.TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> EMCO -3390 1/2112023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI 1200 Pg.18 2 drop tubes <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> Ldivision <br /> ertify that the OPE was inspected in accordance with California Code of Regulations, title <br /> 3, chapter 16, section 2637.2;that required supporting documentation is attached;and <br /> tioncontained herein is accurate. I understand that test procedures shall be made <br /> pon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 11/17/2021 <br /> Page 1 of 2 <br />