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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 /> 5/10/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Stockton Gas <br /> Business Site Address City ZIP Code <br /> 713 N EI Dorado Street Stockton 95202 <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 /> Alan Johnson (800) 339-9930 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804904 8162513 2/27/2021 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> INCON 1001973708 <br /> 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑ Manufacturer Guidelines (Specify) : <br /> Used : <br /> ❑x Industry Code or Engineering Standard (Specify) : PEI-1200 <br /> ❑ Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 12 <br /> TANK ID : (By tank number, stored product, etc.) T-1 : 87 30,000 T2 : 91 12,000 T3 : DSL 8,000 <br /> What is the tank inside diameter? (Inches) 119 .00" 119.00" 119.00" <br /> Is the fill piping secondarily contained? 0 Yes ❑ No El Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <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 /> ❑ <br /> (Check all that apply.) Restricts FlowZ ❑ Restricts Flow El Restricts Flow ' El Restricts FlowZ <br /> ❑ AN Alarm ' ❑ AIV Alarm ' ❑ AN Alarm ' ❑ AN Alarm ' <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes R No ❑ Yes 9 No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set 1 ' 2 3 ' 2 3 ' ] J + 3 ] <br /> to activate? (Inches from bottom of tank.) 105.88"1 108.09 , / 107.75" <br /> What is the percent capacity of the tank at which the ' 2 3 ' 3 ' ] ' ' 2 ' <br /> overfill prevention equipment activates? 941 / 951 / 951 <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 ❑Q Pass ❑ Fail ❑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 /> 1 ECEIV ® <br /> R <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify thatthe 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 aEhl %RONMENTAL HEALTi <br /> UST Service Technician Signatujg VA DEPARTMENT <br /> If the facility has more components 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 /> UNA09 www. unidocs. org 1 /1 - Rev. 06/14/18 <br />