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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 71nspection Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 MoI . - FACILITY INFORMATIONCERS IDDate of Overfill Preven 10181511 4/ 11 / 19 Business Name (Same as Facility Name or DBA-Doing Business As) H & M Market ___ - - ---- — Business Site Address City T95320 P Code 2501 Jackson Ave . Escalon Ila UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Steven White (408) 971 -2445 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 485184 8898679 6/30/22 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) F . F . # 1016243710 OPW # 0179368 III * OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ® Manufacturer Guidelines (Specify) : OPW 71 SO IOM Used : ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. eNo ed Pages TANK ID : (By tank number, stored product, etc.) 1 - Regular 2 - Premium 3 - Diesel What is the tank inside diameter? (Inches) 96" 96" 96" Is the fill piping secondarily contained? ❑ Yes D No ❑ Yes ® No ❑ Yes ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes © No ❑ Yes J❑ No ❑ Yes ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW 71 SO 71 SO What is the overfill prevention equipment response ® Shuts Off Flow ® Shuts Off Flow ® Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) C1 Restricts Flow El Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ A/V Alarm ❑ AIV Alarm ❑ AIV Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ElYes ❑✓ No [:1Yes ® No ElYes ® No 171Yes ❑ No At what level in the tank is the overfill prevention set 90 25" 87 . 36" to activate? (inches from bottom of tank.) - What is the percent capacity of the tank at which the 91 2% 0 overfill prevention equipment activates? 94 . 4 /o - Is the overfill prevention in proper operating condition ® Yes ❑ Yes ® Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ® No (Specify in V.) [INo (Specify in V.) ElNo (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail ❑ Pass ® Fail ® Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section . Any additional comments may also be provided here . 91 Unable to Extract. Will need bucket Replaced . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23 , Division 3, Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual i i i