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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 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181339 4/29/19 Business Name (Same as Facility Name or DBA-Doing Business As) SUPER STOP MARKET Business Site Address City ZIP Code 290 N . MAIN ST MANTECA 95336 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 / 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 , PhikTite & 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 & EMCo ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): # of Pages Pag Attach the inspection procedures and all documentation required to determine the results. Attac6 TANK ID : (By tank number, storedproduct, etc.) 91 DIESEL 87 What is the tank inside diameter? (Inches) 95 95 94 Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes Z No ❑ Yes R No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes N No ❑ Yes ❑x No ❑ Yes Fx� No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) EMCO M OPW OPW A 1100 61 SO 61 SO What is the overfill prevention equipment response ❑x Shuts Off Flow Z Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated? ❑ (Check all that apply.) Restricts Flow El Restricts Flow 171 Restricts Flow El Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ A/V Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? H1 Yes ❑ No Z Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set $ 4 $ 5 $ 3 to activate? (inches from bottom of tank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? 93 89 92 Is the overfill prevention in proper operating condition ❑x Yes ❑x 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 11:79: Pass ❑ Fail Z Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS , r4,� w . Any items marked "Fail" must be explained in this section. Any additional comments ma"! ode-pt pvid'ed�hero w ' � VA VI . CERTIFICATION BY UST SERVICE TECHNICIAN CON TSI , Sf?ECTION 11 E t I hereby = � Division 3 , Crfy that thoverfill hapter 6e Section prevention equipment 2637. 2 and all the information oas n contained herein s accurate' rn,ected in accordance with CaIrpq ,, o Igld gp16t o Title 23, UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, ANAudible and usual =