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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 X 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181267 10/5/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> CALIFORNIA NATIONAL GUARD - STOCKTON AIRPORT <br /> Business Site Address City ZIP Code <br /> 2000 STINSON RD . STOCKTON , CA 95206 <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 /> FELIX RAMIREZ (209 ) 744-0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1740 5-31 - 18 8883072- UT 11 /22/2018 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> OPW 104634 3- 14-20 I <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INF <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : OPW OCT 19 2018 <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : H <br /> DFIDARTMENT <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) AV Gas <br /> What is the tank inside diameter? (Inches) 128 <br /> Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes H No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? ❑x Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) <br /> ❑ AIV Alarm ❑ AN Alarm ❑ AIV Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑X No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 115 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 % <br /> Is the overfill prevention in proper operating condition Z Yes ❑ Yes ❑ 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 ❑ Pass ❑ Fail ❑ 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <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 /> i <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AIV = Audible and Usual <br />