HomeMy WebLinkAbout001- _ Appendix IX
Underground Storage Tank
Overfill Prevention Equipment Inspection Report Form
TYPE OF ACTION FF -1 Installation 0 Repair Q 36 Month
1. FACILITY INFORMATION
CERS ID
Inspection Date
10/6/2021
Facility Name
VALERO
Facility Address
1129 UNION AVE,
City
BAKERSFIELD
ZIP Code
93307
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Inspection
BSSR INC,
Phone
661-588-2777
Mailing Address
6630 ROSEDALE HWY #B
Service Technician Performing Inspection
MICHAEL ENGLISH
Contractor/Tank Tester License Number
BSSR INC, / #672812
ICC Number
5257290
Expiration Date
3/24/23
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training Certifications
Expiration Date
OPW-VR-102 #142568
5/15/22
4. INSPECTION PROCEDURES INFORMATION
Inspection Procedures Used
Components Inspected
VISUAL
OVERFILL PREVENTION DEVICE
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION
I hereby certify that the OPE was inspected in accordance with California Code of
Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting
documentation is attached; and all information contained herein is accurate. I understand
that test procedures shall be made available upon request by the governing authority.
Service Technician Signature
Date
10/6/2021
Total # of Pages
2
s
CERS = California Environmental Reporting System, ID = Identification, ICC = International Code
Council, OPE = Overfill Prevention Equipment
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