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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 [:136 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10761034 17/22/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARCO AM/PM#83831 <br /> Business Site Address City ZIP Code <br /> 1904 Daniels St Manteca 95337 <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 /> Guadalupe Sanchez 925 470-0803 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 4/5/2021 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> OPW 0163755 Exp Date* 617/2021 FFS EVR PHASE I SYSTEMS -VR-1 01 Exbre& 3/4/2020 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method used: ®Manufacturer Guidelines(Specify)OPW Overfill Valve in Tank Shut off Level Worksheet <br /> ❑Industry Code or Engineering Standard(Specify) <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 product,etc.) T1: 87 N T1: 87 S <br /> What is the tank inside diameter?(inches) 118 118 <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 /> OPW OPW <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment ®Shuts Off Flow ®Shuts Off Flow [I Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> (Check all that apply.) ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ®No ❑Yes ®No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention 103 102 <br /> set to activate?(inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 93 92 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating ®Yes ®Yes ❑Yes ❑Yes <br /> condition to respond when the substance ❑No ❑No ❑No ❑No <br /> reaches the appropriate levet? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ®Pass ❑Fail I ® Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> All items marked'Fail'must be explained in this section. Any additional comments may also be provided here.. <br /> .d <br /> Lr . <br /> ENVIRONMENTA_ i <br /> F <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,division 3, <br /> 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 accom odates,additi al copies of this page maybe attached. <br /> r.FRs=rarer,FnvfmrvTw*A Rorw,kMm Nmcm rn=r�r+,-+rte, r RT=r r d efnrwno tank rrr.=1rdPm=fkvvA r.Ip Cru uv-11 AN=e i uiihta aM vim W <br />