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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) <br /> Type of Action r Installation Test I- Repair Test W 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection: <br /> 10165823 7/21/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> 7-ELEVEN#17647, MKT 2368(N-744) <br /> Business Site Address City: Zip: <br /> 1048 W.YOSEMITE AVE @ EL PORTEL MANTECA 95336 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Jesus Saldivar (800)800-4633 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/13/2021 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> ICC-CA UST Service Technician 8361393 06/13/2021 Tanknology Certification-Level III Spill Container Testing Certification Exam 115240 <br /> 06/09/2022 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> W Manufacturer Guidelines(Specify) OPW <br /> Test Method Used: r Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> r <br /> Engineered Method(Specify) <br /> Attach the testing procedures and all documentation required to determine the results. #of Attached Pages: <br /> 1 <br /> Tank ID: (By tank number, stored product, etc.) T-1 T-2 <br /> What is the tank inside diameter?(Inches) 89.75 in. 89.75 in. <br /> Is the fill piping secondarily contained? r Yes r No r Yes r No r Yes r No r Yes r No <br /> Is the vent piping secondarily contained? I✓ Yes r No r Yes r No r Yes r No r Yes F No <br /> Unknown Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> OPW OPW <br /> Shuts Off Flow W Shuts Off Flow r Shuts Off Flow I—Shuts Off Flow <br /> What the overfill prevention equipment response r"Restrict Flow f Restrict Flow F Restrict Flow I—Restrict Flow <br /> when activated?(Check all that apply.) r AA/Alarm r AA/Alarm AA/Alarm r AA/Alarm <br /> Are flow restrictors installed on vent piping? r Yes P— No r Yes P No r Yes r No r Yes r No <br /> At what level in the tank is the overfill prevention set to 80.5 80 <br /> activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the <br /> 95 94 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition r Yes 170 Yes r Yes r Yes <br /> to respond when the substance reaches the r No I— No r No r No <br /> appropriate level? in section v (Specify ) (Specify' ) (Specify ) <br /> (Specify ) (Speci in section Vin section Vin section V <br /> N. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results P-1 Pass r Fail 17 Pass r Fail r Pass r Fail r Pass r Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations,title 23,division 3,chapter 16,section <br /> 2637.1 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> A,ww- <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br />