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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection E] Repair Inspection 0 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS 1D Date of Overfill Prevention Equipment Inspection <br /> 10120456 18/15119 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Rancho San Miguel Market <br /> Business Site Address City ZIP Code <br /> 1427 S . Airport Way Stockton 95206 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the iCC Certification) one # <br /> Steve White (408) 971 m2445 <br /> Contractor / Tank Tester License # iCC Certification # ICC Certification Expiration Date <br /> 485184 8898679 5/ 10/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> 1016243710 / C24135 <br /> Ill . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify): OPW <br /> Used: <br /> E] 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 <br /> TANK iD: (By tank number, stored product, etc.) T2 91 <br /> What is the tank inside diameter? (Inches) 112 <br /> Is the fill piping secondarily contained? E] Yes E] No © Yes E] No E] Yes E] No E] Yes 0 No <br /> Is the vent piping secondarily contained? E] Yes E] No E] Yes © No ❑ Yes [] No 0 Yes E] No <br /> Overfill Prevention Equipment Manufacturer(s) OpW <br /> 61 -SO <br /> What Is the overfill prevention equipment response ❑ Shuts Off FI 21 Shuts Off Flow E] Shuts Off Flow E] Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) M Restricts Flow ❑ Restricts Flow E] Restricts Flow E] Restricts Flow <br /> E] AN Alarm 0 AN Alarm E] AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping? 0 Yes E] No 0 Yes E] No D Yes E] No D Yes E] No <br /> At what level In the tank is the overfill prevention set <br /> to activate? (inches from bottom of tank.) 98. 75 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93 , 3% <br /> Is the overfill prevention in proper operating condition n Yes ® Yes E] Yes 0 Yes <br /> to respond when the substance reaches the <br /> appropriate level? E] No (Specify in V.) E] No (Specify in V.) E] No (Specify in V.) El No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass [] Fail Pass E] Fail ❑ Pass Q Fail E] Pass El Fail <br /> V. COMMENTS <br /> Any items marked 'Fail' must be explained in this section. Any additional comments may also be provided here. <br /> Have to return to remove 87 drop tube <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was 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 J <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 StorageTank, ICC = International Code Council, AN = Audible and Usual <br />