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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> (� Repair Test <br /> 36 Month Test <br /> Type of Action Installation Test <br /> L FACILITY INFORMATION <br /> Date of Overfill Prevention Equipment Inspection : <br /> 9/212020 <br /> CERS ID MEMNON <br /> 10165857 Business As .) <br /> Business Name (Same as Facility Name or DBA-Doing Zip . <br /> 7-ELEVEN #19976 , MKT 2368 City: 95336 <br /> MANTECA <br /> Business Site Address <br /> 1399 N . MAIN ST. @ NORTHGATE <br /> 11, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Phone # <br /> the Test (Print as shown on the ICC Certification . ) (800) 800-4633 <br /> Name of UST Service Technician Performing <br /> Clint Fuhrman ICC Certification Expiration Date <br /> tCC Certification # 5/2/2021 <br /> Contractor/Tank Tester License # 9160945 <br /> Class A General Engineering 743160 p licable certifications.) <br /> Spill Container Testing Training and Certifications (List a p <br /> OPW - EVR Phase 1 904272 05/23/2021 11 11 <br /> Ip, OVERFILL PREVENTION EQUIPMENT INSPECTION INFORON <br /> MAT11 I11 ON <br /> V ' Manufacturer Guidelines ( pecity) QPW <br /> IndustCode or Engineering Standard (Specify) PEI RP 1200 <br /> Test Method Used : Industry # of Attached Pages: <br /> r Engineered Method (Specify) 1 <br /> Attach the testing procedures and all documentation required to determine the results. <br /> T4: UNLEADED T5:PREMIUM <br /> Tank ID : (By tank number, stored product, etc.) 89 .75 in <br /> � Yes r No 90 . 38 in . . <br /> ('" Yes No <br /> What is the tank inside diameter? (Inches) r Yes r No r Yes r No <br /> secondarily contained ? (" Yes r No r Yes r No <br /> Is the fill piping (� Yes r No TV' Yes r No <br /> Is the vent piping secondarily contained ? Unknown <br /> Unknown <br /> Overfill Prevention Equipment ManufacturerOPW OPW <br /> ( Shuts Off Flow <br /> (V. Shuts Off Flow r Shuts Off Flow r Restrict Flow <br /> (✓'. Shuts Off Flow ("; Restrict Flow <br /> r Restrict Flow <br /> lr Restrict Flow r Alarm AN Alarm <br /> What is the overfill prevention equipment response r, AN Alarm r AIV Alarm <br /> when activated ? (Check all that appy .) r Yes r No r Yes r No <br /> FYes � No r Yes r No <br /> Are flow restrictors installed on vent piping ? 80 <br /> At what level in the tank is the overfill prevention set to <br /> 78 <br /> activate? (Inches from bottom of tank. ) 93 94 <br /> What is the percent capacity of the tank at which the Yes <br /> overfill prevention equipment activates? r Yes r Yes <br /> (+r Yes rNo rNo <br /> Is the overfill prevention in proper operating condition r No S eci in section V) <br /> S in section V) (Specify in section V) <br /> No <br /> appropriate level? ( p <br /> to respond when the substance reaches the (Pe� in section V) (Specify <br /> IV. SUMMARY OF TESTING RESULTS <br /> r Pass r Fail r Pass r Fa <br /> Overfill Prevention Inspection Results rV Pass r Fail rV Pass r Faily. COMMENTS <br /> lso be provided here , <br /> ailed above must be explained in this section . Any additional comments may a <br /> All items marked f <br /> �. CERTIFICATION BYUSTSERVICE TECHNICIAN CoNRegulat oDUCTING ns fitle 23 , division 3 , chapter 16 , secti <br /> 1 hereby certify that the spill containers were tested u accordance with Califor <br /> 2637 .1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> a may be attached . <br /> If the facility has more components than this form accommodates , additional copies of this page <br /> ' Environmental Reporting System, ID=Identification , UST=Underground storage tank, ICC=International Code Counc <br /> nia il <br /> CERS=Califor <br />