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Apponft IX <br />Underground Storage Tallk <br />Overfill Prevention Equipment 1'nspertion Report FOrIll <br />TYPE OF ACTION 0 RepairL <br />36 Month <br />A I�ITY INFORIVIATI®N_ . <br />Inspection Date <br />CERS I® f 1 d 1 Za 1 <br />Facility Name <br />City 71P Code <br />Facility AddressSc, G'3p <br />AvQ- <br />�IaI VIC :Y`t;CWNI IAN IN MATION..: . <br />Phone <br />Company Performing the inspection f 7ng1 ��,� o �,��� <br />Mailing Address <br />r <br />o 4eif4—rmn�lng , 30' <br />Service Technician inspection <br />Contractor/Tank Tester License Number <br />3 Expiration Date <br />ICC Number <br />tl� 6 � <br />3 TR�►INtN�.:AI ®C�RTIFpATIONS <br />Expiration Da <br />Manufacturer <br />Manufacturer and Test Equipment Training Codifications <br />()?W 1 f0S 3� � _ � � l2C>� <br />�. <br />lnspecfion Procedures Used <br />1v <br />INFCRMAi°IQN <br />Components Inspected <br />-C RTI ,ICATION-BY SERVICE TECHN]UAN: CN. tJGT.INC INSP C.TIO <br />1 hereby certify that the ®>'E was Inspected in accordance with Californiaoda <br />Regulations, title 23, division 3, chapter 96, seof <br />ction 263.2; that required pf� <br />documentation is attached; and all information contained herein is accurate. I understand <br />that lest procedures shall be made available upon request by the governing authority. <br />Date Total tf of Pages <br />Service Technician Inature , <br />CERS = California Environmental Reporting System, ICS = Identification, ICC � International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />