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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page -I of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180675 11 - 15- 18 Business Name (Same as Facility Name or DBA-Doing Business As) FAST N EASY Business Site Address City ZIP Code 11399 E YOSEMITE MANTECA 1 95336 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) one # David Winkler (209 ) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11 - 16 - 18 OPW 104-633 Ex 3 - 14-2020 Emco #3207 Ex . 09-21 -2020 VR : B34975 ATG : 2/8/20 I III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method X Manufacturer Guidelines (Specify) : REMOVED OPW DROP TUBES Used : D E C s 3 2018 ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : 'ENVIr i I .vi ITAIL HEALTH Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID : (By tank number, storedproduct, etc.) 87 91 DSL What is the tank inside diameter? (Inches) 92 92 92 Is the fill piping secondarily contained? ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes ❑x No ❑ Yes H Nox No Yes ❑ No ❑ Yes ❑ El Overfill Prevention Equipment Manufacturer(s) OPW opw opw 61so 61so 61 so What is the overfill prevention equipment response ZShuts Off Flow X Shuts Off Flow Z Shuts Off Flow E] Shuts Off Flow when activated ? (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 823/4 821 /4 82 What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 94 94 Is the overfill prevention in proper operating condition 0 Yes Q Yes 0 Yes ❑ Yes to respond when the substance reaches the appropriate level ? ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Z Pass ❑ Fail Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail' must be explained in this section . Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate. UST Service Technician Signature V j If the facility has more components than this form accommodates, additional copies of this page maybe attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Cale Coundl, AA/ = Audible and Visual