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 <br />10181359 - San Joaquin EMD <br />Inspection Date <br />10/29/2024 <br />Facility Name <br />Gavinko Gas <br />Facility Address <br />7700 Moreland St <br />City <br />Stockton <br />ZIP Code <br />95212 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />BZ Service Station Maintenance, Inc <br />Phone <br />916-371-2380 <br />Mailing Address <br />1041 Triangle Ct, W Sacramento, CA 95805 <br />Service Technician Performing Inspection <br />Roland King <br />Contractor/Tank Tester License Number <br />433159 <br />ICC Number <br />9719084 <br />Expiration Date <br />5/20/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW - 1195390 <br />3/30/2025 <br />4. INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />PEI 1200 pg.18 <br />3 drop tubes <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. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service echni ' n Signature <br />Date <br />10/29/2024 <br />Total # of Pages <br />9 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />