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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel of 1) <br /> Type of Action ❑ Installation Inspection ❑Repair Inspection N 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10180529 1/25/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> J AND L MARKET <br /> Business Site Address City ZIP Code <br /> 8115 E ELDORADO ST FRENCH CAMP <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 Dale <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 104-634 Ex 3-14-2020 <br /> Emco 3147 Ex. 11-16-20 VR: 834976 ATG: 7/7/20 Incon 1009883708 Ex 11-30-20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION I14"— 10 <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: OPW REMOVE DROP TUBE <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> ENVIRONMENTAL HEALTH <br /> Attach the inspection procedures and all documentation required to determine the results. #6 ENT 4 <br /> TANK ID:(By tank number,storedproduct etc.) 87 91 DIESEL <br /> What is the tank inside diameter?(Inches) 96 96 96 <br /> Is the fill piping secondarily contained? ❑Yes O No E Yes E°' No ❑Yes ❑p No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes ❑x No ❑Yes ❑• No ❑Yes E• No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW oPw <br /> 6180 61 50 6150 <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow E Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow [I Restricts Flow El Restricts Flow ElRestricts Flow <br /> ❑AA1 Alarm ❑A/V Alarm ❑AIV Alarm ❑AIV Alarm <br /> Are flow restriclors installed on vent piping? ❑Yes I]No ❑Yes ❑' No ❑Yes E• No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 86 86 86 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94% 940 94% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑■ Yes E Yes <br /> to respond when the substance reaches the <br /> appropriate level? I ❑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 N Pass ❑Fail ❑x Pass ❑Fail ❑x Pass —DFafl1r E 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 thatthe 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 U ' <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Ca6fomia Environmental Reporting System,ID=Idenfificalion,LIST=Underground Storage Tart,]CC=International Code Council,AA/=Audible and usual <br />