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W . O . # NW1 - 2338748 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Paas 1 of 1) <br /> Type of Action ❑ Instatiation Inspection ❑ Repak Inspection 0 36 Month inspection <br /> In FACILITY INFORMATION <br /> CERS ID Dale of Overfill Prevention Equipment Inspection <br /> 10165857 10/11 /2018 <br /> Business Name (Same as Fooft Name or DBA-0oft Buskwa As) <br /> 7-Eleven #19976 <br /> Business Site Address City ZIP Code <br /> 1399 N Main Street Manteca 95336 <br /> Ii. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Tedunl lan Performing the Inspection (Print as shorn on the ICC Ceriffivatlon.) Phone # <br /> Darren Sciume (800) 964-0010 <br /> Contractor I Tank Tester Ucense # ICC Certification # ICC Certification Expiration Date <br /> 743160 8223550 5/27/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (list applicable certifications.) <br /> OPW Phase 1 UST EVR <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method 0 Manufacturer Guidelines (Specify): OPW <br /> Used: <br /> ❑ industry Code or Engkmeerig Standard (Spero): <br /> ❑ Engineered Method (Specify): <br /> Attach Bre inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID: (By tank number, stored product etc.) T4:Unleaded T5:Premium <br /> What Is the tank inside diameter? (Inches) 90.375 89.75 <br /> Is the fill piping secondarily contained? 0 Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? 0 Yes ❑ No 19 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manrdacturen(s) OPW OPW <br /> What is the overfill prevention equipment response 0 Shuts Off Flow 0 Starts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ AfV Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow reskictors installed on vent piping? ❑ Yes 0 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) 78 80.56 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 86% 88% <br /> Is the overfill prevention in proper operating condition 0 Yes 0 Yes <br /> to respond when the substance reaches the ❑ Yes ❑ Yes <br /> appropriate level? ❑ No (Specffy in V.) ❑ No (Specify In V.) ❑ No (Specify in 1d) ❑ No (SpeaYy in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results JIMPass ❑ Fail I 0 Pass ❑ Fait ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any Hems marked 'Fair must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill nequipment was inspected Inaccordance with California Code ofR <br /> eaulaUons, Tide 23, <br /> Division 3, Chapter 16, on 637.2 alt the information contained heroin is accurate. <br /> UST Service Technician <br /> if Me heUfty has more c this form accommodates, addlUonal copies of this paps may bo adachsd. <br /> CERS = CaifmiaBr6rxmar WPePalf V9501 M D=kierifimlmm, UST= Underground SbWTB* ICC =tdemolon alC xJeCa r4 AN =Aid leamdVlauei <br />