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UNDERGROUNDSTORAGETANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel of 1) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180567 6/24/2019 Business Name(Same as Facility Name or DBA-Doing Business As) EMILS Business Site Address City ZIP Code 1405 CALIFORNIA ST ESCALON 95320 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certfcation.) Phone# David Winkler 1 (209) 744-0112 Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) FF- EBW , Phil-Tite &EVR Phase 1 1009853708 Ex 11/29/20 OPW 104-633 Ex 3-14-2020 Emco #3207 Ex. 11/16/20 ATG: VR: B34975 ATG: 2/8/20 INCON 1009853708 Ex.11/30/2020 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines(Specify): Used: REMOVED OPW DROP TUBES ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 5 TANK ID:(By tank number,stored product,etc.) 87 91 DSL What is the tank inside diameter?(Inches) 128 128 128 Is the fill piping secondarily contained? ❑Yes ❑x No ❑Yes 0 No ❑Yes E No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes ❑x No ❑Yes 0 No ❑Yes Z No ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) DPW DPW DPW 61so 61so 61so What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x 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 ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes 0 No ❑Yes ❑x No ❑Yes [:1 No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 112 1/2 1121/2 124 What is the percent capacity of the tank at which the overfill prevention equipment activates? 93 93 99 Is the overfill prevention in proper operating condition ❑x Yes Yes ❑Yes ❑Yes to respond when the substance reaches the E]appropriate level? No(Specify in V.) [INo(Specify in V.) ❑Q No(Specify in V.) ElNo(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑Q Pass ❑ Fail 11 ❑Q Pass ❑ Fail ❑Pass ❑x Fail ❑ Pass ❑Fail V. COMMENTS Any items marked"Fail'must be explained in this section. Any additional comments may also be provided here. DSL FAILED TO HIGH NEEDS NEW DROP TUBE AND RETEST ASAPF `11' ** Donlee To repair and retest DIE OF RECER, 1111 1 R '�0.10 VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPEC"I''ION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, Division 3, Chapter 16,Section 2637.2 and all the information contained herein is accurate. riONMEN : __-; UST Service Technician Signature DEPARTMENT If the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AW=Audible and Visual