Laserfiche WebLink
Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION r-1 Installation Ej Repair ® 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10186837 08/15/2022 <br /> Facility Name <br /> Manteca Gas& Food <br /> Facility Address City ZIP Code <br /> 1229 E. Louise Manteca 95336 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Elite IV Contractors (209)461-6337 <br /> Mailing Address <br /> 2535 Wigwam Dr Stockton, CA 95205 <br /> Service Technician Performing Inspection <br /> Benjamin Malaspina <br /> Contractor/Tank Tester License Number <br /> Elite IV Contractors 1001331 <br /> ICC Number Expiration Date <br /> 9519380 06/17/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS EVR Phase1 systems -VR101 1019683711 08/23/2023 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> Manufacture Standards 87, 91 and Diesel droptube overfill prevention <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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 08/15/2022 2 <br /> L-c . <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />