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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 /> 10182093 2/28/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> KWIK SERV <br /> Business Site Address City ZIP Code <br /> 950 WEST 11TH STREET 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 /> Felix Ramirez 1 (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1740 Ex. 03/31/2020 8883072-UT 11/9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- FF- EBW , Phil-Tite & EVR Phase 1 1009883708 EX 11-29-20 OPW 104- f -14-2020 <br /> Emco 3147 Ex. 11-16-20 VR: B34976 ATG: 7/7/20 Incon 1009883708 Ex 11- IJ— <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTIO I ORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): OPW REMOVE DROP TUBES MA <br /> Used: <br /> ❑ Industry Code or Engineering Standard(Specify): MENTAL HEA <br /> ❑Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 3 <br /> TANK ID: (By tank number,stored product, etc.) 87 91 DIESEL <br /> What is the tank inside diameter?(Inches) 92 92 92 <br /> Is the fill piping secondarily contained? ❑Yes Fm] No ❑Yes 0 No ❑Yes [E No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes [j] No ❑Yes M No ❑Yes 0 No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> 61 so 61 SO 61 SO <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 /> ❑AN Alarm ❑A/V Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes Z No ❑Yes 0 No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 81 81 81 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93% 93% 93% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑X Yes 0 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 i]Pass ❑Fail Q Pass ❑Fail 11 0 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 equipmentwas 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 /> (I <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,AN=Audible and Visual <br />