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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 /> 11 Will liiiiiiiiiiiiiiiiiiiiilill� <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment inspection <br /> 10182243 11 /26/2019 <br /> Business Name (same as Facility Name or DBA-Doing Business As.) <br /> MAIN STREET ARCO AM PM ZIP Code <br /> Business Site Address 77=Manteca <br /> 1100 S Main St 195337 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the !CC CelPhone # <br /> Guadalu a Sanchez 925 470 - 0803 Ext. <br /> Contractorrrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 100054445250451 4/5/2021 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications) 3/04/2020 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> inspection Method Used : ^ neer Overfill Bialy T Shut off I eveel Worksheet <br /> p ® Manufacturer Guidelines (Specify) <br /> ❑ Industry Code or Engineering Standard (Specify) <br /> i <br /> [I Engineered Method (Specify) <br />€, Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages: 15 <br /> Tank ID: (By tank number, stored product, etc.) T1 : 87 West T1 : 87 East T2 : 91 T3 : 89 <br /> What is the tank Inside diameter? (inches) 117 117 117 <br /> Is the fill piping secondarily contained? ® Yes [I No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ® No ❑ Yes No ❑ Yes No ❑ Yes No <br /> OPW OPW OPW OPW <br /> Overfill Prevention Equipment Manufacturers) <br /> What is the overfill prevention equipment ® Shuts Off Flow ® Shuts Off Flow ® Shuts Off Flow ® Shuts Off Flow <br /> response when activated? ❑ Restricts Flow [I Restricts Flow ❑ Restricts Flow [I Restricts Flow <br /> (Check ell that apply) ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes ® No ❑ Yes No ❑ Yes ® No El Yes ® No <br /> At what level in the tank is the overfill prevention 105 105 104 104 <br /> set to activate? (inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 94 94 94 94 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating IR Yes ® Yes ® Yes ® Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention inspection Results ® Pass ❑ Fail ® Pass [:1 Fail ® Pass [I Fail ® Pass ❑ Faii <br /> V. COMMENTS <br /> All items marked 'Fail" must be explained In this section. Any additional comments may also b vi dtre� I a <br /> All drop tubes were replaced f <br /> a <br /> lit" <br /> F P ' xv g • s <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, division 3, <br /> 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, ad tonal copies of this page maybe attached. <br /> r:FRR o rar*%mia Fmr wwurawMaf RomMrm CvaMm in a ktomm itinn i LCT I } mm+ mrl gMratwfank IrY: : rntomark j r"IP P.n+ mrD aN = of viliNa and viwwr <br />