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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action N Installation Inspection El Repair Inspection ❑X 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID 10180913 Date of Overfill Prevention Equipment Inspection <br /> 1/28/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> ERNIES GEN STORE <br /> Business Site Address City ZIP Code <br /> E WATERLOO RD � STOCKTON 95215 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> David Winkler 1 (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11/29/20 OPW 104-633 Ex 3-14-2020 <br /> Emco #3207 Ex. 11/16/20 ATG: VR: B34975 ATG:2/8/20 INCON 1009853708 Ex.11/30/2020 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: OPW DROP TUBES <br /> ❑ Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 3 <br /> TANK ID:(By tank number,stored product etc.) 87 91 DSL <br /> What is the tank inside diameter?(Inches) 120 120 120 <br /> Is the fill piping secondarily contained? ❑Yes ❑x No ❑Yes ❑x No ❑Yes 0 No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes 0 No ❑Yes IE No ❑Yes 0 No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) o P w <br /> 71 SO 71 So 7i SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑A/V Alarm ❑AA/Alarm ❑A/V Alarm ❑AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes [E No ❑Yes 0 No ❑Yes R No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 101 3/4 102 106 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 91.2 91.5 94.5 <br /> Is the overfill prevention in proper operating condition ❑x Yes Z Yes ❑x Yes ❑Yes <br /> to respond when the substance reaches the <br /> El level? No(Specify in V) ElNo(Specify in V.) ElNo(Specify in V.) ElNo(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑Fail 11 ❑x Pass ❑ Fail Z Pass ❑Fail q.P ss ❑ Fail <br /> V. COMMENTS <br /> Any items marked"Fail'must be explained in this section. Any additional comments may also be provided here. <br /> FEB 0 6 zon <br /> ENTAL HEALTH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCIINGT A T <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council,AN=Audible and Visual <br />