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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> —✓ Type of Action ® Installation Inspection 0 Repair Inspection ❑ 36 Month Inspection <br /> L FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181511 11 !7/ 19 <br /> Business Name (Same as Facility fume or DBA-Doing Business As) <br /> H&M Market <br /> Business Site Address c <br /> ity ZIP Code <br /> 2501 Jackson Ave calon 95320 <br /> 11 , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Kristopher Bell (408) 971 -2445 <br /> Contractor / Tank Tester License # ICG Certification # ; ICC Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> F . F . # 1004933708 <br /> OPW # 902968 <br /> Ill , OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines <br /> Used: (Specify) : Defender <br /> ❑ Industry Code or Engineering Standard (Specify): <br /> ❑ Engineered Method (Specify): <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.) 2-Premium <br /> What is the tank Inside diameter? (Inches) 96" <br /> Is the fill piping secondarily contained? ❑ Yes ❑ No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? <br /> ❑ Yes ❑ No ❑ Yes © No F1 Yes ❑ No [I Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) EBW Defender <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ® Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ AN Alarm ❑ A/V Alarm ❑ AN Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes ❑ No ❑ Yes Z 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.) 841 /8 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93 % <br /> Is the overfill prevention in proper operating condition ❑ Yes 0 Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> [Iappropriate level ? No (Specify in '/.) ❑ No (specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV, SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass ❑ Failaaj 0 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 /> Completed Overfill Inspection due to Drop Tube Replacement <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 /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = Cagwia Environmental Repotting System, ID = kierMcation, UST = Underground Storage Tank, )CC = Internationa) Code Courxd, A/V = Audliie and Visual <br />