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H <br />UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection 77 <br />I. FACILITY INFORMATION <br />CERS ID <br />10181267 <br />Date of Overfill Prevention Equipment Inspection <br />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 <br />2000 STINSON RD. <br />City <br />STOCKTON, CA <br />ZIP Code <br />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.) <br />FELIX RAMIREZ <br />Phone # <br />(209) 744-0112 <br />Contractor I Tank Tester License # <br />08-1740 5-31-18 <br />ICC Certification # <br />8883072-UT <br />ICC Certification Expiration Date <br />11/22/2018 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />OPW 104634 3-14-20 -% <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INF <br />Inspection Method <br />Used: <br />❑x Manufacturer Guidelines (Specify): <br />OPW OCT 19 2018 <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />DFIDARTMENT <br />rrl <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />AV Gas <br />What is the tank inside diameter? (Inches) <br />128 <br />Is the fill piping secondarily contained? <br />ElYes ❑x No <br />[IYes [INo <br />ElYes ❑ No <br />❑ Yes ElNo <br />Is the vent piping secondarily contained? <br />ElYes 0 No <br />❑ Yes ElNo <br />ElYes ❑ No <br />ElYes ElNo <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />ElShuts Off Flow <br />❑x Restricts Flow <br />ElAIV Alarm <br />E]Shuts Off Flow <br />ElRestricts Flow <br />El AA/ AAlarm <br />ElShuts Off Flow <br />❑ Restricts Flow <br />ElAIV Alarm <br />ElShuts Off Flow <br />ElRestricts Flow <br />E]AIV Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes ❑X No <br />❑ Yes [:1No <br />❑ Yes ❑ No <br />ElYes ElNo <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />115 <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />90% <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />Z Yes <br />ElNo (Specify in V.) <br />El Yea <br />❑ No (Specify in V.) <br />L1Yes <br />ElNo (Specify in V.) <br />ElYes <br />ElNo (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />❑x Pass E]Fail <br />E]Pass El Fail <br />ElPass ElFail <br />ElPass ElFail <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 <br />facility has more components <br />than this <br />form accommodates, additional copies of this <br />page maybe attached. <br />CERS <br />= California Environmental Reporting <br />System, ID <br />=Identification, UST =Underground Storage Tank, ICC = <br />International Code Council, AN =Audible and Usual <br />' <br />