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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181441 10/3/2018 Business Name (Same as Facility Name or DBA-Doing Business As) RIVER POINT LANDING Business Site Address City ZIP Code 4950 BUCKLEY COVE WAY STOCKTON , CA 95267 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # DAVID WINKLER (209 ) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 104-633 Ex 3- 14-2020 Emco Ex. 10- 1 -20 VR : B34975 ATG : 2/8/20 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : REMOVED DROP TUBE ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID : (By tank number, storedproduct, etc.) 87 DIESEL What is the tank inside diameter? (Inches) 96 96 Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes 0 No ❑ Yes Z No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPw oPw 6150 7150 What is the overfill prevention equipment response ❑x Shuts Off Flow 0 Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes [E No ❑ Yes ❑X No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 851 /2 85 . 6 What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 % 94 % Is the overfill prevention in proper operating condition ❑x Yes 0 Yes ❑ 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 0 Pass ❑ Fail ❑x Pass ❑ Fail [:] Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. �,4AY 17 2019 VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCT T H IS 11 SPEC TION I hereby certify that the overfill prevention equipmentwas 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 V If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, A/V = Audible and Usual