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UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) <br /> Type of Action r Installation Test r Repair Test F/— 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection: <br /> 10166191 1 10/26/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> 7 ELEVEN 35355 <br /> Business Site Address City: Zip: <br /> 3202 W HAMMER LANE(N-136) STOCKTON 95209 <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 /> Michael Deatherage (800)800-4633 <br /> ContractorlTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Class A General Engineering 743160 8819901 11/7/2019 <br /> Spill Container Testing Training and Certifications(List applicable certifications.) <br /> OPW-EVR Phase 1 166344 10/20/2019 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Manufacturer Guidelines(Specify) OPW <br /> Test Method Used: r Industry Code or Engineering Standard(Specify) PEI RP 1200 <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.) T1: <br /> What is the tank inside diameter?(Inches) 117.75 in. <br /> Is the fill piping secondarily contained? r Yes r No r Yes r No rYes r No rYes r No <br /> Is the vent piping secondarily contained? r Yes r No r Yes r No rYes r No rYes r No <br /> Overfill Prevention Equipment Manufacturer(s) Unknown <br /> OPW <br /> What is the overfill prevention equipment r Shuts Off Flow r Shuts Off Flow rShuts Off Flow r—.Shuts Off Flow <br /> response when activated? r Restrict Flow r Restrict Flow r Restrict Flow r Restrict Flow <br /> (Check all that apply.) rA/VAlarm rA/VAlarm rA/VAlarm rA/VAlarm <br /> Are flow restrictors installed on vent piping? r Yes r No ryes r No rYes r No rYes r No <br /> At what level in the tank is the overfill prevention <br /> set to activate?(Inches from bottom of tank.) 109.25 <br /> What is the percent capacity of the tank at <br /> which 97.4 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating r Yes r Yes r Yes r Yes <br /> condition to respond when the substance r No r No r No r No <br /> reaches the appropriate level? (Spesify in section V) (Spesify in section V) (Spesify in section V) (Spesify in section V) <br /> N. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results r Pass r Fail I r 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 USTSERVICE 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, <br /> section 2637.1 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 />