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1 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action Z Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181295 10/9/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> DIAMOND GAS & FOOD <br /> Business Site Address City ZIP Code <br /> 824 E . YOSEMITE AVENUE MANTECA 95331 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) Phone # <br /> Zane Nimmo (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04- 1676 Ex . 03/31 /2019 8883064-UT 6/ 1 /2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications) <br /> FF- EBW , PhikTite & EVR Phase 1 10009843708 Ex 11 - 16- 18 OPW 104-632 Ex 3- 14-2020 <br /> Emco 3206 Ex. 9/21 /2020 VR: A28446 ATG : 9/28/19 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used: OPW PHASE I INSPECTION GUIDELINES <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 3 <br /> TANK ID : (Bytanknumber, stored product etc.) 1 - 87 OCT 2 - 89 OCT 3 - 91 OCT <br /> What is the tank inside diameter? (Inches) 95 . 5 " 95 . 5 " 95 . 5 " <br /> Is the fill piping secondarily contained? ❑ Yes 2 No Z Yes Z No ❑ Yes E No ❑ Yes Z No <br /> Is the vent piping secondarily contained? ❑ Yes Z No Z Yes ❑x No ❑ Yes Z No ❑ Yes Z No <br /> Overfill Prevention Equipment Manufacturer(s) oPw OPw OPw <br /> What is the overfill prevention equipment response Zx Shuts Off Flow ❑x Shuts Off Flow Q Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ A/V Alarm Z A/V Alarm Z A/V Alarm Z A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes Zx No Z Yes R No Z Yes Z No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 84 . 5 84 . 0 84 . 0 <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 Yes 0 Yes Zx Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) Z No (Specify in V.) Z No (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail ❑x Pass ❑ Fail Zx 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 /> JAN 2 2 2019 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> r . <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 /> 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 = Intemational Code Council , AN = Audible and Visual <br />