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20201392 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL. PREVENTION EQUIPMENT INSPECTION REPORT FORM {Page 1 of i) <br /> Type of Adion ❑ Installation Inspection 0 Repair Inspection 0 38 Month inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Dote or Overfill Prevention Equipment Inspection <br /> 10180733 6/18/2020 <br /> Business Name (Same as Facft Name or M& Dohrp Bustnass As) <br /> Arco 7147 <br /> Business Site Address City ,ZIP Code <br /> 1206 E March Lane Stockton 95210 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Tectancian FWarr ring the Inspection (Print as shown on the ICC Cartolcatfon.) Phone 0 <br /> Darnell Smith (925) 551 .7555 <br /> Contrectori Tank Tester Ucense s ICC Cenlacatlon a ICC Cedifcallon Expiration nate <br /> 220793 8709494 11 /23/2021 <br /> Overfill Prevention EWpment Inspection Training and Certifications (list appaeame eerw asUont) <br /> OPW Cert# 017405 Exp. 7/1112020 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method © Manufacturer Suldell nes (Spedly)c <br /> used: Tank Chart, OPW, Tape Measure <br /> O Industry Code or E%Inaerhng Standard (Spec*)t <br /> 0 Engloeerad Method (Spat fyr <br /> Attach the Inspection procedures and all documentation required M determtne the results, * of Attached pages <br /> TANK ID: (9y rank number, stored product, eta) 87 T1 1 91 T2 DSL T3 <br /> what Is the tank khsbie dianhsler? (Whes) 90.5 90. 5 90. 5 <br /> Is the fill ping secondarily contakhed? 0 Yes I@ No 0 Yes IN No 0 Yes (@ No 0 Yes 0 No <br /> Is Me vent Piping se=da* contained? 0 Yes 0 No 0 Yes IN No 0 Yes 17 No 0 Yes 0 No <br /> Overfill Prevention Equonent Mauarradwads) voodor sow wader Rom vee(w Root <br /> What Is the overfill prevention eq4ment response 0 Shuts agFlow ❑ Shuts ()If Flow 0 Shuts Ort Flow 0 Shuts Off Flow <br /> when activated? <br /> (Check am that aPPIy,) 0 Rest►Ids Flow 0 Restdds Flow 0 Restdds Flow 0 Restricts Flow <br /> © W Alarm I] AN Alarm IM AN Alarm 0 AIV Alarm <br /> Are Row mstr1dors insieW on vent palling? 0 Yes CI No O Yea ® No 0 Yes t@ No O Yes 0 No <br /> oaci� tMk � m� prevention set activate? fmmmottank) 767/8 76 718 767/8 <br /> What Is Urs percent capacity of the tank at which the <br /> ovedN prevention egrtpment activates? 90 90 90 <br /> Is the overfill pravwwon In proper operallm condition ® Yes OM Yes Q Yes 0 Yes <br /> to respond when the substance reaches the <br /> approodew Ievd? 0 No (Spodyin V.) C7 No (S;m* In V.) 0 No (Spodty In V.) O No (Spediy1n V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> OvWQ Prevention Inspection Results ® Pass 13 Fa 0 Pass 0 Fax 0 Pass 0 Fag ❑ Pass 0 Fax <br /> V. COMMENTS <br /> Any items marked lFaIrmust be explained in this section. Any additional comments may also be provided here. <br /> Via CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> 1 hereby certify that the overfill proventlon equipment wase Inspected in accordance with CaUfornia Code of Regulations, Tille 23, <br /> Divlaton 3, Chapter 16, Section 2637.2 a Ined ha In Is accurate, <br /> UST Service Te "clan Signature <br /> tf the fadltty has more components than tblbdarts, addttforM copies of this page maybe attached <br /> CERS= CagmmiaErWAnT htdlRepwft5yskiiiIDR46 16 0 n, USTMVndayoundSWmpTartkICC= hAanWa CofeCour4A1VaAutMandVmW <br />