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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action El Installation Inspection ❑ Repair Inspection Z 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181059 10/4/2018 Business Name(Same as Facility Name or DBA-Doing Business As) Quik stop market# 138 Business Site Address City ZIP Code 1153 Lincoln Blvd. Tracy 95376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Rey Hernandez (916) 373-1166 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 617238 8712763 5/8/2019 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) Phase 1 EVR- CERT#0154742 RECEIV Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMAT19NT 1 1 2018 Inspection Method ❑x Manufacturer Guidelines(Specify): Used: OPW Install & Maintenance Guidelines ❑ Industry Code or Engineering Standard (Specify): ENVIRON MARTMENIT ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages TANK ID: (By tank number,stored product,etc.) Gasoline - 87 Gasoline - 89 Gasoline - 91 What is the tank inside diameter?(Inches) 89 3/4" 89 3/4" 89 3/4" Is the fill piping secondarily contained? I]Yes ❑No R1 Yes ❑ No [E Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? 0 Yes ❑No El Yes ❑ No E Yes ❑No ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) oPw oPw opw What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activateda (Check all that apply.) Restricts Flow ❑x Restricts Flow Z Restricts Flow ElRestricts Flow ❑A/V Alarm ❑AA/Alarm ❑A/V Alarm ❑AA/Alarm Are flow restrictors installed on vent piping? ❑Yes Z No ❑Yes [E No ❑Yes R No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 80 3/8" 80 3/8" 80 1/4" What is the percent capacity of the tank at which the overfill prevention equipment activates? 95% 95% 95% Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑Yes to respond when the substance reaches the appropriate level? ❑No(Specify in V) ❑No(Specify in V.) ❑No(Specify in V) ❑ No(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ZPass ElFail ZPass ❑Fa`ij Z Pass ❑ Fail ❑Pass ❑Fail V. COMMENTS Any items marked"Fail'must be explained in this section. Any additional comments may also be provided here. On site for overfill inspection test. Tested site with passing results VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accogftnodates,additional&ies of this page may be attached. CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AIV=Audible and Visual