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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action © installation Inspection ❑ Repair Inspection [:136 Month Inspection 1 . FACILITY INFORMATION CERS ID 10181433 Date of Overfill Prevention Equipment Inspection 5!9/19 Business Name (Same as Facility Name or DBA-Doing Business As) Unocal255886 Business Site Address City ZIP Code 2701 West March lane Stockton 95219 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Eusebio Sousa 1 (707) 545-5522 Contractor / Tank Tester License # `ICC # 77/18/19 Certification Expiration Date Able Maintenance, Inc, - 312844 5454516-UT Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW EVR Phase 1 - UST 100414 Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ® Manufacturer Guidelines (Specify): Used : OPW 71SO ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 91 What is the tank Inside diameter? (inches) 111 .5" 111 .5" Is the fill piping secondarily contained? ® Yes ❑ No JZ] Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW 71 SO 71 SO What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) ® Restricts Flow ® Restricts Flow ❑ Restricts Flow [I Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ® Yes ❑ No M Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level In the tank is the overfill prevention set to activate? (inches from bottom of tank.) 97 , 75" 97 .75" What Is the percent capacity of the tank at which the overfill prevention equipment activates? 92 , 9% 92 .9% Is the overfill prevention in proper operating condition ® Yes ® Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V) ❑ No (Specilyin V) ❑ No (Specify in V.) ❑ No (Speciiyin V) IV . SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fa(I ❑ Pass ❑ Fail =0P s ❑ Fail V . COMMENTS Any items marked "Fail° must be explained in this section. Any additional comments may also be provided here. Installed New Drop Tubes - Tested & Passed. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 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 If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = CaKomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = international Code Council, AN Audible and Visual