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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10180637 2/21/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> GEMCO RIPON TRUCK PLAZA <br /> Business Site Address City ZIP Code <br /> 1022 S. FRONTAGE ROAD RIPO N 95366 <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 /> Zane Nimmo 1 (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, Phil-Tite &EVR Phase 1 10009843708 Ex 11-29-20 OPW 104-632 Ex 3-14-2020 <br /> Emco 3206 Ex. 11/14/2020 ATG: VR:A28446 Ex. 9/28/19 Incon# 1009843708 Ex.11- - <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFO _ <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): 0 <br /> Used: O P W PHASE I TESTING <br /> ❑Industry Code or Engineering Standard(Specify): 3 MY <br /> ❑Engineered Method(Specify): <br /> :�WVJkONMENTA" AL1 <br /> Attach the inspection procedures and all documentation required to determine the results. #of Fy R� V 4 <br /> TANK ID: (By tank number,stored product,etc.) 1 - 87 OCT 2 - 91 OCT <br /> What is the tank inside diameter?(Inches) 113.75 113.75 <br /> Is the fill piping secondarily contained? ❑Yes 0 No ❑Yes 0 No ❑Yes ❑No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes [ No ❑Yes E] No ❑Yes ❑No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) oPw oPw <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow E]Restricts Flow El Restricts Flow E]Restricts Flow <br /> ❑A/V Alarm ❑A/V Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes Z No ❑Yes I]No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 98.0" 99.0 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 91% 92% <br /> Is the overfill prevention in proper operating condition ❑x Yes Z Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑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 ❑x Pass ❑Fail ❑X Pass ❑Fail ❑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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was 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=CaGfomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />