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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type ofAction ❑ Installation Inspection ❑ Repair Inspection N 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181241 1 /30/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> PARKWOOD SHELL <br /> Business Site Address City ZIP Code <br /> 1612 W Hammer Lane Stockton 95209 <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 /> Zane Nimmo 1 ( 209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04- 1676 Ex. 03/31 /2019 8883064-UT 6/ 1 /2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications) <br /> FF- EBW , PhikTite & EVR Phase 1 10009843708 Ex 11 -29-20 OPW 104-632 Ex 3- 14-2020 <br /> Emco 3206 Ex. 11 /14/2020 ATG : VR: A28446 Ex. 9/28/19 Incon # 1009843708 Ex . 11 -30-20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : OPW <br /> Used : <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 3 <br /> TANK ID: (By tank number, stored product, etc.) 1 - DIESEL <br /> What is the tank inside diameter? (Inches) 96 <br /> Is the fill piping secondarily contained? ❑ Yes x❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes I] No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) VEEDER ROOT <br /> What is the overfill prevention equipment response NShuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> ❑ <br /> (Check all that apply) Restricts Flow El Restricts Flow ❑ Restricts Flow I] Restricts Flow <br /> ❑ A/V Alarm ❑ AIV Alarm ❑ A/V Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes Z 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.) 82a5" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 91 % <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑ Yes ❑ 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 E] Fail E] Pass ❑ Fail E] Pass ElFail El Pass !' ❑ aii <br /> V. COMMENTS <br /> Any items marked `Fail" must be explained in this section. Any additional comments may als& b provided here. <br /> MAR , 5 2019 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTI HIS;INSPECTION <br /> 1 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 <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, AA/ = Audible and Visual <br />