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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 <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10182109 2/25/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> ABC PETROLEUM <br /> Business Site Address City ZIP Code <br /> 2375 N . TRACY BLVD TRACY 95376 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) Phone # <br /> Edward Stearns (209 ) 744- 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 09/30/2020 888308MT 11 /9/2020 _ <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-63 A;202 <br /> Emco 3205 Ex . 11 / 16/2020 ATG : VR A31048 Ex. 8/9/ 19 Incon 1009893708 11 / 0/ v <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMA . 1_ ; 02 ,q <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : REMOVE AND INSPECT OPW <br /> ❑ Industry Code or Engineering Standard (Specify) : ENVIRONNNI N TAL IHS V <br /> -, i�Klxll <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 <br /> TANK ID : (By tank number, stored product, etc.) 1 -87 2-91 3-DIESEL <br /> What is the tank inside diameter? (Inches) 91 91 91 <br /> Is the fill piping secondarily contained? ❑ Yesx❑ No ❑ Yes ❑x No ❑ Yes [] No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes N No ❑ Yes N No ❑ Yes 0 No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow 0 Shuts Off Flow ❑x 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 /> ❑ AIV Alarm ❑ A/V Alarm ❑ AIV Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes Z No ❑ Yes 0 No ❑ Yes 9 No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 80 81 81 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93 . 5 94 . 4 94 . 4 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results E Pass ❑ Fail Z Pass ❑ Fail ❑Q 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> hereby certify that the overfill prevention equipment was 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 may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemalional Code Council, AN = Audible and Usual <br />