Laserfiche WebLink
Appendix IBC <br /> Under round Storage Tank <br /> Overfill Prevention Equipment Inspe tion Report Form <br /> TYPE OF ACTION ', Installation Repair 36 Month <br /> 1. FA IUTY INIFORMATfON - — -- — <br /> ERS ID Inspection bate <br /> — - -— -- _--- -- -1 - 0 5 <br /> Facility Dame <br /> Gas and Shad <br /> Facility Address =city !P Code <br /> 1002 Frontage Road Ripon Ca 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> crnpany Performing the Inspection Phone <br /> Self Serve Petro leg,M (650)5B8- 088 <br /> Mai Iing Address — - --- <br /> 1G45 Airport Blvd, South San i~rancism C a 94080.. _ <br /> Service Technician Performing Inspection <br /> Robert Neim yer _ <br /> ontractorJTank Tester License Number <br /> Gen A / Haz 1 OM05 <br /> ICC Number Expiration Date <br /> 5248067 10-10-202 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Cerfta6ons Expiration Date <br /> OPW 10100 2-1 - 07 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Proce6ures Used componenfs inspected <br /> PEI ! 1V re uls� arand_super <br /> b, CERTIFICATION BY SERVICE TECHNICIAN CONDUCTIN 4NSP�DTION -- <br /> f hereby certify that the OPE was inspected to accordance with Califomia Code of <br /> Regulatians, title 23, division S. chapter 16, section 263 7. ; that required supporting <br /> doe urnenta tion is attached; and all info rma(ion Contained herein Is accurate. f finderstarrd <br /> that test procedures shall be made available upon request by the governing authorlt . <br /> Service TeChniciar} Signature -- - -- Date Total # of Pages <br /> r a x -13-2025 <br /> DERS = Califomia Environmental Reporting Systern, ID = Identification, ICC = Wnternational Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />