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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of 1) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181565 1/15/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> PERSHING GAS FOR LESS <br /> Business Site Address City ZIP Code <br /> 4445 PERSHiNG AVE [ STOCKTON 95207 <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 (209) 744-0112 <br /> Contractor 1 Tank Tester License# ICC Certification# ICC Certification Expiration Dale <br /> 08-1740 Ex. 03/31/2020 8883072-UT 1119!2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) n ?° E <br /> �` <br /> FF-FF- EBW, Phil-Tits & EVR Phase 1 1009883708 EX 11-29-20 OPW 104-63Ri <br /> 4 14-202 <br /> >.A� <br /> Emco 3147 Ex. 11-16-20 VR: B34976 ATG: 717120 Incon 1009883708 Ex 11-30- 0 '" <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATM 2 Q 2019 <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: OPW REMOVE DROP TUBES <br /> ❑ Industry Code or Engineering Standard(Specify): ENVIRONMENTAL <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 3 <br /> TANK ID:(By tank number, stored product, etc.) 87 91 DIESEL <br /> What is the tank inside diameter?(inches) 92 92 92 <br /> Is the fill piping secondarily contained? ❑Yes ❑x No ❑Yes ❑x No ❑Yes [E No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes 9 No ❑Yes ❑x No ❑Yes El No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> 71 SO si so 61 SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow Z Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flaw ❑ Restricts Flow El Restricts Flaw El Restricts Flow <br /> ❑AN Alarm ❑AIV Alarm ❑AfV Alarm ❑AN Alarm <br /> Are flow restrictors installed an vent piping? ❑Yes 0 No ❑Yes 0 No ❑Yes Z No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 82 81 82 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% 94% 95% <br /> Is the overfill prevention in proper operating condition ❑x Yes Z Yes 19 Yes ❑Yes <br /> to respond when the substance reaches the <br /> E]appropriate level? No(specify in V.) E] No(Specify in V.) ElNo(Specify in V) ❑No(Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 71IR Pass ❑Fail 11 Z Pass ❑ Fail 0 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 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 r( 7) <br /> 4 <br /> lithe facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Cabibmia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council,AW=Audible and Usual <br />