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,Adis , <br /> lJndre � rEB__Sa� _ { <br /> Le <br /> eyenti€_n E tit eoI~ �. <br /> TYPE QF ACTIC lnsfallation, a C Month <br /> 1. C T C) <br /> CERS ID Inspec#ion Date <br /> —- 10779784 12/09/2021 <br /> Facility Name City Gas & Liquor <br /> Facilit Address Cit _ ZIP Code <br /> 16470 Cambridge St. Hrop 95330 <br /> Company Performinc the Ins_.ection Phone <br /> Elite IV Contractors (209) 461-6337 <br /> Maifin Address 2535 Wigwam Dr Stockton, Ca 95205 <br /> Service Tecl,ni ian Performin Iction. <br /> Michel Kennard <br /> Contactor ank Tester I-icen e umber 10Q1331 A- HAZ <br /> ICC Number 5254811 Expiration Date 7/06/2023 <br /> �. TRAlMC AND CERTIFICATES <br /> Manufacturer and Test E ui menf Trainina C rtifieafions �xpirafian Qafe <br /> OPW EVR VR-102 5119123 <br /> SP CTIOt PROCEDURES INFORMATI014 <br /> Inspection—Procedures—Us—ed Components Inspected <br /> Visual Over Fill Flapper 1 Drop Tube 1 Ball Floats <br /> 5. CERTIFICATION DY SERthe fhnf the QPE Was V#CE TEC�INICIaN CONDUCTIhIC IN�PIrTjOt <br /> 'n ince with Califnruia Cade of <br /> thofid� <br /> r[QGumenfatian is eftsed herein is accurate—I understand <br /> r i { h y r <br /> ServLce Technician Signature - Date Total of Lads <br /> 12109f21 2 <br /> CFS = California E�viro_nment �eortinpte.m�IDIdentification, ICC = Ipternational Code <br /> Cour�c.. Q '_.E.._=Qverfill Prexention Eauip_men <br /> Page.of 2 <br />