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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 FC1 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 09-26-2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Quik Stop #125 <br /> Business Site Address City ZIP Code <br /> 1580 W. Main St. Ripon 95366 <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 /> Max Hines, Don Solamon (209) 599-4261 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8750053 11/9/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> OPW 100565 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: OPW IriStall &M1lnteri3Ce Guidelines <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.) 87 91 Diesel <br /> What is the tank inside diameter?(Inches) 89 3/4" 89 3/4" 89 3/4" <br /> Is the fill piping secondarily contained? ❑x Yes ❑No x❑Yes ❑No ❑x Yes ❑ No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑x Yes ❑No 0 Yes ❑No ®Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? Restricts Flow Q Restricts Flow i]Restricts Flow ❑Restricts Flow <br /> (Check all that apply.) <br /> ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes ®No ❑Yes [j]No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 80 3/8" 80 3/8" 80 3/8" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90% 92% 91% <br /> Is the overfill prevention in proper operating condition ❑x Yes ®Yes N 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 Z Pass ❑Fail I ❑x Pass ❑Fail ❑x 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 /> 1 hereby certify that the overfill prevention equipmentwas inspected in accordance with C e& 1 2 <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurat . <br /> EO <br /> UST Service Technician Signature <br /> LOCT <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,AIV=Audible and Visual <br /> ENVIRONMENTAL <br />