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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 3/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> California Stop <br /> Business Site Address City ZIP Code <br /> 2224 S Manthey Rd TStockton , CA 95026 <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 /> Brian Dunahay (415) 315 - 9638 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 956593 8021436-UT 12/16/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> A ` i > " 3 <br /> Overfill Cert : PEIRP1200 10/9/2018 I ' + <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method e- <br /> p ❑ Manufacturer Guidelines (Specify) : <br /> Used : <br /> Z Industry Code or Engineering Standard (Specify): RP1200 <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) 87 91 Diesel <br /> What is the tank inside diameter? (Inches) 92 <br /> Is the fill piping secondarily contained ? El Yes El No El Yes 0 No El Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑ No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow Q Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm ❑ A/V 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.) 82 OO <br /> What is the percent capacity of the tank at which the 94 <br /> overfill prevention equipment activates? <br /> I Is the overfill prevention in proper operating condition ❑ Yes Z Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> Elappropriate level? No (Specify in V.) [INo (Specify in V.) ElNo (Specify in V.) ElNo (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass ❑ Fail 0 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 /> 87 and Diesel were tested and passed on 1 /16/2019 . <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 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />