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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 ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181209 2/25/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> SB GAS & MARKET <br /> Business Site Address City ZIP Code <br /> 515 W. 11TH ST TRACY 95376 <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 /> Edward Stearns (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 09/30/2020 8883080- UT 11 /9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3- 14-2020 <br /> Emco 3205 Ex . 11 / 16/2020 ATG : VR A31048 Ex. 8/9/19 Incon 1009893708 11 /30/2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify). <br /> Used : REMOVE AND INSPECT OPW <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 4 <br /> TANK ID : (By tank number, storedproduct, etc.) 1 -87 2-91 3-DIESEL <br /> What is the tank inside diameter? (Inches) 95 . 75 95 . 75 95 . 75 <br /> Is the fill piping secondarily contained ? ❑ Yes El No ❑ Yes n No ❑ Yes [E No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑x No ❑ Yes Z No ❑ Yes x❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW PW OPW <br /> 6150 61SO 61SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow x❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> E A/V Alarm E A/V Alarm ❑ AIV Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑X No E Yes E No ❑ Yes ❑x No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 86 . 1 85 85 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94 93 93 <br /> Is the overtill prevention in proper operating condition ❑x Yes ❑x Yes ❑x 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 0 Pass ❑ Fail ❑x Pass ❑ Fail ❑x 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was 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 />