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UNDRGROUN ED STORAGE TANK r OVERFILL PREVENTION EQUIPMENT �€CTION° REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 14 36 Month Inspection 1. FACILITY��tf�11=0�M�4TIQN CERS ID Date of Overfill Prevention Equipment inspection. Ipt� Business Name (Same as Facility Name or DBA-Doing Business As.) Business Site Address City ZIP Code (S'. A .Kz zci Y 11 . UNDERGROUND: STORAGE T41i :S,E1VICE. TECHNICIA : INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) Phone # Tony Fontana 209 595 - 4489 Ext. Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date A-846288 11064273 5- 1 -2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications) W C11 `Zld _ j Ill. OVERFILL PREVENTION Owl Q* INSPECTi N INFORMATION Inspection Method Used : ® Manufacturer Guidelines (Specify) inStallatlOn instru tions ❑ 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) What is the tank inside diameter? (Inches) �$ A 2 " Is the fill piping secondarily contained? ❑ Yes Ad No ❑ Yes ,� No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes 9 No ❑ Yes No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment Shuts Off Flow Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow response when activated? El Restricts Flow ❑ Restricts Flow El Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑ A/V Alarm ❑ AIV Alarm ❑ AN Alam ❑ AN Alam Are flow restrictors installed on vent piping? ❑ Yes No ❑ Yes No ❑ Yes ❑ No ❑ Yes ❑ No { At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) brj What is the percent capacity of the tank at which the overfill prevention equipment activates? qS11IO Is the overfill prevention in proper operating XYes Yes ❑ Yes ❑ Yes condition to respond when the substance El No No ❑ No ❑ No reaches the appropriate level? S No m section V. (Specify ) (Specify in section V.) (Specify in section V.) (Specify in section V) IV. S.UMMARIEO:>~ IION: RESULTS Overfill Prevention Inspection Results Pass ❑ Fail YPass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Faii V. ;COIIIrtEUTS All items marked "Faii' must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERV/ICE T iliC}AN CONDUCTING THIS' INSPECTION [chapter reby certify that the overfill prevention equipment was inspected in,accordance with California Code of Regulations, title 23, division 3, 16, section 2637.2 and all the information contained hereinis accurate, Service Technician Signature If the facility has more components than is fo accommodates, additional copies of this page maybe attached.