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 101812378 Inspection Date 7/2/24 <br /> Facility Name WOODBRIDGE AMPM <br /> Facility Address City ZIP Code <br /> 18806 LOWER SACRAMENTO RD WOODBRIDGE 95258 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> NOR-CAL TANK TESTING 209-712-6366 <br /> Mailing Address 877 BATEMAN WAY GALT CA 95632 <br /> Service Technician Performing Inspection David Winkler <br /> Contractor/Tank Tester License Number 08.1739 Ex.2/28/26 <br /> ICC Number Expiration Date <br /> 8883059-UT 01/30/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11/29/24 <br /> Emco #3207 Ex. 2/24/23 ATG: VR: B34975 ATG: 2/8/22 INCON 1009853708 Ex.11/11/2024 <br /> OPW 104-633 03/10/26 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> OPW FLAPPERS <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 /> Corvir= T=nhnininn Cirrnn+imn Date Total # of Pages <br /> w7/2/24 2 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />