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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 ❑ 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10120456 10/08/19 <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 /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Steven White 4089712445 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8898679 05/ 10/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> 1016243710 / C24135 <br /> Ilia OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify) : OPW <br /> Used : <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 <br /> TANK ID : (By tank number, stored product, etc.) T1 -87 <br /> What is the tank inside diameter? (Inches) 119 <br /> Is the fill piping secondarily contained ? ❑✓ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑✓ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes [] No <br /> Overfill Prevention Equipment Manufacturer(s) OPW <br /> 71 -SO <br /> What is the overfill prevention equipment response ® Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow ❑ Restricts Flow [I Restricts Flow ❑ Restricts Flow <br /> ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping ? 0 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.) 98 . 75 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates ? 91 , 8 % <br /> Is the overfill prevention in proper operating condition ® Yes ❑ Yes ❑ Yes ❑ 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 ® Pass ❑ Fail I ❑ 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 /> 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 Signatures Y <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 />