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RECEIVED 0 0 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> ENVl stallation Inspection ❑Repair Inspection N 36 Month Inspection <br /> DEPARTMENT I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 9/24/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Quik Stop 39 <br /> Business Site Address City ZIP Code <br /> 2285 E. Fremont Street Stockton 95205 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Matthew Jensen 1 (916) 372-1888 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8025471 2/2/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> OPW <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: OPW <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,storedproduct,etc.) 1.Gasoline-87 2.Gasoline-91 <br /> What is the tank inside diameter?(Inches) 89.75 89.75 <br /> Is the fill piping secondarily contained? 0 Yes ❑No I]Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow [j Shuts Off Flow <br /> when activateda <br /> (Check all that apply) ❑x Restricts Flow ®Restricts Flow ❑Restricts Flow E]Restricts Flow <br /> ❑A/V Alarm ❑AA/Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ®No ❑Yes ®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.) 81.25 81 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? <95 <95 <br /> Is the overfill prevention in proper operating condition [E Yes Z Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? E]No(Specify in V.) ❑No(Specify in V. El (Specify in V.) ElNo(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 9 Pass ❑Fail ❑x 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 /> 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//A— <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=CaGfomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />