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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 /> 10151123 1 10-17-19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Sprint Stockton <br /> Business Site Address City ZIP Code <br /> 3807 Coronado Ave Stockton 95204 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Peter Jaure ui III 760 743-0518 Ext. <br /> ConLractorfTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 708231 8195227 5-29-21 <br /> Overfill Prevention Equipment Inspection Training and Certifications(list applicable certifications.) <br /> OPW 904559 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: IZ Manufacturer Guidelines(Specify)OPW <br /> EI Industry Code or Engineering Standard(Specify)PE11200 <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.) Diesel <br /> What is the tank inside diameter?(Inches) 89.75" <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) veeder-root <br /> opw <br /> What is the overfill preventionequipment ®Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> p ❑Shuts Off Flow <br /> response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> (Check all that apply.) ®AN Alarm <br /> ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are floe,restrictors installed on vent piping? ❑Yes ®No ❑Yes <br /> ❑No El Yes ❑No El Yes ❑No <br /> At what level in the tank is the overfill prevention 75,803/8 <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 90.95 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating ®Yes =(Specify <br /> ❑Yes ❑Yes <br /> condition to respond when the substance <br /> reaches the appropriate level? ❑N0 ❑No ❑No <br /> (Specify in sectio (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ®Pass ❑Fail ❑Pass <br /> V. COMMENTS ❑❑Fait ❑Pass ❑Fail Pass <br /> -0F a,l <br /> All items marked'Fail'must be explained in this section. Any additional comments may also be provided here. <br /> A new OPW71 SO-41 OCT Valve was installed and set to shut off at 95% <br /> i <br /> i <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 / 2 <br /> If the facility has more components than Wis forrh accommodates,additional copies of this page may be attached. <br /> CEZS=California Errvironmental Reporting System,ID=Identification UST=Underground storage tanto ICC=International Code Council,AN=Audible and visual <br />