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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action F] installation Inspection El Repair Inspection 0 36 Month Inspection 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10182043 5/31 /2019 Business Name (Same as Facility Name or DBA-Doing Business As) EL DORADO GAS MART Business Site Address City ZIP Code 1605 S . EL DORADO ST TSTOCKTON __. 95206 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Edward Stearns (209 ) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 14- 1760 Ex . 09/30/2020 8883080- UT 11 /9/2020 Overrill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3- 14-2020 Emco 3205 Ex . 11 / 16/2020 ATG : VR A31048 Ex. 8/9/ 19 Incon 1009893708 11 /30/2020 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : REMOVE AND INSPECT Used : ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages4 TANK ID : (By tank number, stored product, etc.) 87 91 What is the tank inside diameter? (Inches) 127 . 50 127 . 50 Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No EIs the vent piping secondarily contained? ❑ Yes N No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW 61 SO 61 SO What is the overfill prevention equipment response ❑x Shuts Off Flow Z Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply) El Restricts Flow [:1Restricts Flow ❑ Restricts Flow El Restricts Flow ❑ A/V Alarm ❑ AIV Alarm ❑ A/V Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set 115 115 . 2 to activate? (Inches from bottom of tank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 . 9 94 . 8 Is the overfill prevention in proper operating condition ❑x Yes Z Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level ? ElNo (Specify in V.) 1771No (Specify in V) ElNo (Specify in V) ElNo (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑ Fail Z Pass ❑ Fail [:] Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. RA i 1 FJ A; :J VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TW § INSPECTION I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637 .2 and all the information contained herein is a _ , UST Service Technician Signature , , . ARTMENT, If the facility has more components than this form accommodates, additional copies of this page may be attached. = Audible and Usual CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN