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r�tL�+vtu <br />UNDERGROUND STORAGE TANK i'JI i U 2020 <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection t n <br />I. FACILITY INFORMATION .. T n .;\e <br />CERS ID <br />10181511 <br />Date of Overfill Prevention Equipment Inspection <br />14/11/19 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />H&M Market <br />Business Site Address <br />2501 Jackson Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <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 />Steven White <br />Phone # <br />(408) 971-2445 <br />Contractor / Tank Tester License # <br />485184 <br />ICC Certification # <br />8898679 <br />ICC Certification Expiration Date <br />16/30/22 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />F.F. # 1016243710 <br />OPW # 0179368 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />m Manufacturer Guidelines (Specify): OPW 71 SO IOM <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <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 />1 - Regular <br />2 - Premium <br />3 - Diesel <br />What is the tank inside diameter? (Inches) <br />96" <br />96" <br />96" <br />Is the fill piping secondarily contained? <br />❑ Yes ® No <br />❑ Yes © No <br />❑ Yes ® No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes © No <br />❑ Yes © No <br />❑ Yes 0 No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW <br />OPW <br />71 SO <br />71 SO <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />m Shuts Off Flow <br />❑ Restricts Flow <br />❑ AIV Alarm <br />m Shuts Off Flow <br />❑ Restricts Flow <br />❑ A/V Alarm <br />m Shuts Off Flow <br />❑Restricts Flow <br />❑ A/V Alarm <br />❑ Shuts Off Flow <br />E] Restricts Flow <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes 0 No <br />❑ Yes 0 No <br />❑ Yes [0 No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />90.25' <br />- <br />87.36" <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />94.4% <br />- <br />91.2% <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />m Yes <br />[]No (Specify in V.) <br />❑ Yes <br />® No (Specify in V.) <br />® Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results11Pass E]Fail <br />I E]Pass 0 Fail 1 ® Pass ElFail ElPass ❑ Fail <br />V. COMMENTS <br />Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. <br />91 Unable to Extract. Will need bucket Replaced. <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 a" <br />If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />CERS = California Environmental Reporting System, ID = identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />