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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page I of 1) <br /> Type of Action 0 installation inspection 0 Repair inspection Z 36 month inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspeotion <br /> 1 9/24/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> IDA Stop #124 <br /> Business Site Address City ZIP Cod <br /> 505 N/ in St. Manteca 95336 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of LIST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) -Phone# <br /> Juan Jauregui (916) 889-3897 <br /> Contractor 1 Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 5246964 8/30/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Phase 1 EV R -Cert# 100580 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method El Manufacturer Guidelines(Specify): <br /> Used: <br /> [I industry Code or Engineering Standard(Specify): <br /> E]Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID:(Bytanknumber,storedproduct,etc,) Gasoline - 87 Gasoluine - 89 asoline - 91 <br /> What is the tank inside diameter?(Inches)hes - <br /> 'n- 89 3/4 89 3/4" 89 3/4" <br /> Is the fill piping secondarily contained? Yes []No El Yes 0 No 2 Yes No ❑Yes E]No <br /> Is the vent piping secondarily contained? E Yes El No 2 Yes C]No 2 Yes ONo 0 Yes [I No <br /> Overfill Prevention Equipment Manufacturer(s) OPW opw OPW <br /> What is the overfill prevention equipment response [I Shuts Off Flow El Shuts Off Flow El Shuts Off Flow E]Shuts Off Flow <br /> when activated? Restricts Flow [E Restricts Flow 2)Restricts Flow [I Restricts Flow <br /> (Check all that apply.) <br /> [I A/V Alarm CJ A/V Alarm 0 AN Alarm El AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes M No C3 Yes [2 No El Yes [0 No 0 Yes EINo <br /> At what level in the tank is the overfill prevention set <br /> to activate?(inches from bottom of tank.) 80 3/8" 80 3/8" 80 1/4" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% 95% 95% <br /> Is the overfill prevention in proper operating condition Yes Yes 9 Yes 0 Yes <br /> to respond when the substance reaches the <br /> appropriate level? I C]No(Specify in V.) E]No(Specify in V.) El No(Specify in V) El No(Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results N Pass 0 Fail 9 Pass ®Fail ®Pass ❑Fail ®Pass ®Fail <br /> V. COMMENTS <br /> Any items marked' must be-explained in this section. Any additional comments may also be provided here. <br /> V1. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with Call-fo _PE <br /> Division 3,Chapter 16,§ection 2 7.2 and all the information contained herein is accurate. <br /> Chapter <br /> '6, ction 2 72 <br /> LIST Service Techn n Sign <br /> I t is <br /> s )r-r 25 13 Lulo <br /> if the facility has mo;Com e Is th "iccommodates,additional copies of this page may be attached. <br /> CERS=California Envi ng Identification,UST=Undefground Storage Tank,tCC=Intemabonal Code Council,AV=Audible and Visual <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />