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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM <br /> Type of Action : ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment <br /> Inspection 4/26/2019 <br /> Business Name Arco AMPM Trinity Pkwy <br /> Business Site Address 10715 Trinity city Stockton zip code <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Service Technician (on ICC Certification ) Darnell Smith Phone # 916-371-2380 <br /> Contractor License #: 433159 ICC Certification : 8709494 ICC Expiration Date : 12/21/2019 <br /> Overfill Prevention Equipment Relevant Certifications ( List Applicable) : <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑ Manufacturer Guidelines (Specify) : <br /> Used : <br /> ® Industry Code or Engineering Standard (Specify) : PEI 1200 Pg. 18 <br /> ❑ Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. # of attached pages : <br /> Tank ID : ( By tank number, stored 87 87 91 DSL <br /> What is the tank inside diameter? ( inches ) 119 119 119 119 <br /> Is the Fill Piping Secondarily contained ? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> Is the Vent Piping Secondarily contained ? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> Overfill Prevention Equipment OPW OPW OPW OPW <br /> Manufacturer <br /> Tank Manufacturer Xerxes Xerxes Xerxes Xerxes <br /> What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> response when activated ? ® Restricts Flow ® Restricts Flow ® Restricts Flow ® Restricts Flow <br /> ( Check all that apply) ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent E] Yes ® No ❑ Yes ® No El Yes ® No El Yes ® No <br /> piping? <br /> At what level in the tank is the overfill <br /> prevention set to activate? ( Inches from 1041/211 105 " 109 " 1091/211 <br /> bottom of tank , ) <br /> What is the percent capacity of the tank at <br /> which the overfill prevention equipment 94% 94% 97% 97% <br /> activates ? <br /> Is the overfill prevention in proper ❑ Yes ❑ Yes ❑ Yes ❑ Yes <br /> operating condition to respond when the ❑ No (Specify in V. ) ❑ No (Specify in V. ) ❑ No (Specify in V. ) ❑ No (Specify in V. ) <br /> substance reaches the appropriate level ? <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail I ® 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 /> REO <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 126W of kegul'ati6fis, Title 23, <br /> Division 3, Chapter 16, Section 2637 . 2 and all the information contained herein is accurate <br /> UST Service Technician Signature ENVIRONMENTAL HEALTH <br /> )� -0� DEPARTMENT <br />