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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 /> 1018085 1/30/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> COUNTRYMART 76 <br /> Business Site Address City ZIP Code <br /> 34243 S CHRISMAN TRACY 95304 <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 /> David Winkler 1 (209) 744-0112 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite &EVR Phase 1 1009853708 Ex 11/29/20 OPW 104-633 Ex 3-14-2020 <br /> Emco #3207 Ex. 11/16/20 ATG: VR: 834975 ATG:2/8/20 INCON 1009853708 Ex.11/30/2020 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: REMOVED DROP TUBE <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 5 <br /> TANK ID: (By tank number,stored product,etc.) 87 91 DSL WEST DSL EAST <br /> What is the tank inside diameter?(Inches) 111.50 111.50 111.50 111.50 <br /> Is the fill piping secondarily contained? ❑Yes i]No ❑Yes Z No ❑Yes [E No ❑Yes 0 No <br /> Is the vent piping secondarily contained? ❑Yes i]No ❑Yes [j]No ❑Yes i]No ❑Yes ❑x No <br /> Overfill Prevention Equipment Manufacturer(s) oPw oPw oPW EBW <br /> 61so 61SO 61so <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow 0 Shuts Off Flow ❑x Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow E]Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑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 set <br /> to activate?(Inches from bottom of tank.) 96 94 1/2 100 841/2 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 91 90 94 81 <br /> Is the overfill prevention in proper operating condition [E Yes 0 Yes (]Yes Q 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 ❑Faill 0 Pass ❑ Fail Z Pass ❑Fail ❑x Pass []FSI <br /> V. COMMENTS <br /> Any items marked"Fail"must be explained in this section. Any additional comments may also be pr ' 4_ 71 W <br /> APR 0 2 2019 <br /> TH <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TH <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code offs , I 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature V � <br /> K the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council,AN=Audible and Visual <br />