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May 04 20 , 02 : 28p p , 3 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of st ) FTypef Action ❑ Installation Inspection ❑ Repair Inspection x❑ 36 Month Inspection ! . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 1016085 1 /30/2019 Business Name (Same as Facility Name or DBA-Doing Business As) COUNTRYMART 76 Business Site Address City ZIP Code 34243 S CHR_ ISMAN TRACY 95304 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Cartification.) Phone # David Winkler (209) 744- 0112 Contractor I Tank Tester License # ICC Certirication # ICC Certification Expiration Date 08-1739 Ex.3/31 /2020 8883059 -UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable cer6frcations) FF- EBW , PhikTite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 314-2020 Emco #3207 Ex. 11 /16/20 ATG : VR : B34975 ATG : 218120 INCON 1009853708 Ex . 11130/2020 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION ssss Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : REMOVED DROP TUBE ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 5 THINK ID : (By tank number, stored product, etc.) 87 91 DSL WEST DSL EAST What is the tank inside diameter? (inches) 111 . 50 111 . 50 111 .50 111 . 50 Is the fill piping secondarily contained? ❑ Yes ® No ❑ Yes ❑Q No © Yes (] No ❑ Yes EjNo Is the vent piping secondarily contained? ❑ Yes M No ❑ Yes ❑x No ❑ Yes I] No ❑ Yes 2 No Ovefill Prevention Equipment Manufacturer(s) CPw OPW OPW Eew 6150 6150 61 SO What is the overfill prevention equipment response N Shuts Off Flow Q Shuts Off Flow 9 Shuts Off Flow © Shuts Off Flow when activated? (check all that apply.) El Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ A(V Alarm Are flow restrictors installed on vent piping? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes I] No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? Onches from bottom of tank.) 96 941 /2 100 841 /2 What is the percent capacity of the tank at which the g 1 go 94 61 overfill prevention equipment activates? Is the overfill prevention in proper operating condition N Yes Q Yes 21 Yes f] Yes to respond when the substance reaches the appropriate level? 4 ❑ No (Specify in V.) [:] No (Specify in V.) ❑ No (Specifyin V.) ❑ No (Specify in V.) N. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results N Pass ❑ Fall N Pass ❑ Fail A Pass ❑ Failix Pass ❑ Fail V. COMMENTS Any items marked `t=ail" must be explained in this section. Any additional comments may also ro7odeo here. AF' I� 0 � 2019 VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING; 'THIS'1 P CTION hereby certify that the overfill prevention equipmentwas inspected in accordance with Califoinia Code of Regulations, Title 23, Division 3, Chapter 16 , Section 26372 and all the information contained herein is accurate, UST Service Tochniclan Signature if the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = underground Storage TanK, iCC = International Code Council, AN = Audible and Visual