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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 El 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181361 2/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> QUICK N EASY <br /> Business Site Address City ZIP Code <br /> 2057 EL DORADO STREET STOCKTON 95206 <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 /> David Winkler ( 209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1739 Ex . 3/31 /2020 8883059-UT 1 /29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , Phil -Tite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 3- 14-2020 <br /> Emco #3207 Ex. 11 / 16/20 ATG : VR: B34975 ATG : 2/8/20 INCON 1009853708 Ex. 11 /30/2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify): <br /> Used : REMOVED OPW DROP TUBES <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 Pages3 <br /> TANK ID: (By tank number, stored product, etc.) 87 91 <br /> What is the tank inside diameter? (Inches) 117 117 <br /> Is the fill piping secondarily contained? ❑ Yes x❑ No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW opw <br /> 61 SO 61 SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow 0 Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ A/V Alarm ❑ AN Alarm ❑ AIV Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes E No ❑ Yes 0 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.) 103 99 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93 90 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x 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.) El No (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 0 Pass ❑ Fail N Pass ❑ Fail ❑ 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 /> LJ <br /> R E <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING tAl NW&ION <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 Tt:RQNMENTAL_ HEALTH <br /> UST Service Technician Signature V �- DEPARTIMI^ NT <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual <br />