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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181209 2 /25/ 19 Business Name (Same as Facility Name or DBA-Doing Business As) SB GAS & MARKET Business Site Address City ZIP Code 515 W. 11TH ST TRACY 95376 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Edward Stearns ( 209 ) 744-0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 14- 1760 Ex . 09/30/2020 8883080- UT 11 /9/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3- 14-2020 Emco 3205 Ex . 11 /16/2020 ATG : VR A31048 Ex . 8/9/ 19 Incon 1009893708 11 /30/2020 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : REMOVE AND INSPECT OPW ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID : (By tank number, storedproduct, etc.) 1 -87 2-91 3- DIESEL What is the tank inside diameter? (Inches) 95 . 75 95 . 75 95 . 75 Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes E No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes [E No ❑ Yes [E No ❑ Yes ❑x No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW PW OPW 61SO 61SO 61SO What is the overfill prevention equipment response ❑x Shuts Off Flow 0 Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated? ❑ (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow ❑ A/V Alarm ❑ AIV Alarm ❑ AIV Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes [j] No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 86 . 1 85 85 What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 93 93 Is the overfill prevention in proper operating condition ❑x Yes Z Yes ❑x Yes ❑ Yes to respond when the substance reaches the appropriate level ? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑x Pass ❑ Fail I Z Pass ❑ Fail j x❑ Pass ❑ Fail IF ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION hereby certify that the overfill prevention equipment was inspected in accordance wifhp��j {�- r,a mode of,Regulations , Title 23 , Division 3, Chapter 16 , Section 2637 .2 and all the information contained herein is accu t € I� 1�1i ` � ! } EAI I 1 UST Service Technician Signature J [7t-. 1 { C= OI If the facility has more components than this form accommodates, additional copies of this page maybe attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Visual