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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection Z 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181307 5/8/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> REFUEL CIRCLE K <br /> Business Site Address City ZIP Code <br /> 419 S. MAIN STREET MANTECA 95366 <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 /> Zane Nimmo 1 (209) 744-0112 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 04-1676 Ex.03/31/2019 8883064-UT 6/1/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW, Phil-Tite &EVR Phase 1 10009843708 Ex 11-29-20 OPW 104-632 Ex 3-14-2020 <br /> Emco 3206 Ex. 11/14/2020 ATG: VR: A28446 Ex. 9/28/19 Incon# 1009843708 Ex.11-30-20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: O P W PHASE I INSPECTION <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.) 1 - 91 OCT 2 - 87 OCT 3 - DIESEL <br /> What is the tank inside diameter?(Inches) 95.7 95.7 95.7 <br /> Is the fill piping secondarily contained? ❑Yes 0 No ❑Yes EINo ❑Yes 0 No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes ❑x No ❑Yes EI No ❑Yes 0 No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) o P w o P w o P w <br /> What is the overfill prevention equipment response Zx 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 /> ❑AA/Alarm Z AIV Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 2 No ❑Yes Z No ❑Yes 0 No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 85.5 81.5 85.5 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94.1 90.5 94.1 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑ No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑X Pass ❑Fail 11 ❑x Pass ❑ Fail ❑x Pass ❑Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked"Fail'must be explained in this section. Any additional comments may also be provided here. <br /> RECEIVED <br /> WW11 <br /> q 2019 <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was 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 acctIRONMENTAL HEALTH <br /> UST Service Technician Signature ,Z DEPARTMENT <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=International Code Coundl,AN=Audible and Visual <br />