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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection S Repair Inspection ❑ 36 Month Inspection 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment inspection 10151123 10-17-19 Business Name (Same as Facility Name or DBA-Doing Business As.) Sprint Stockton Business Site Address City ZIP Code 3807 Coronado Ave Stockton 195204 II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Peter Jaure ui III 760 743 - 0518 Ext, Contractor/Tank Tester Ucense # ICC Certification # ICC Certification Expiration Date 708231 8195227 5-29-21 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) QPW 904559 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: S Manufacturer Guidelines (Specify) 0EW S Industry Code or Engineering Standard (Specify) PEI 1200 ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages: Tank ID: (By lank number, stored product, etc.) Diesel What is the tank inside diameter? (Inches) 89.75% Is the fill piping secondarily contained? ❑ Yes ONO ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes S No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No i veeder-root j Overfill Prevention Equipment Manufacturer(s) opw What is the overfill prevention equipment ® Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apptyj ® AN Alarm ❑ AN Alarm ❑ AN Atertn ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑ Yes S No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention 752803/8 set to activate? (inches from bottom of tank.) What is the percent capacity of the tank at which 90, 95 the overfill prevention equipment activates? Is the overfill prevention in proper operating S Yes ❑ Yes ❑ Yes =ed condition to respond when the substance ❑ No ❑ No ❑ No reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Speciy in secti2V.) V J IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results S Pass [I Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS All items marked TaiPmust be explained in this section. Any additional comments may also be provided here. A new OPW71 S041 OCT Valve was installed and set to shut off at 95% VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature /.p If the facility has more components than Orts forth accommodates, additional copies of this page may be attached. 3 CERS = California Errvironmental Reporting System ID = kkntificatkx% UST = UnderWound storage tank, ICC = International Code Cosnck AN = Audible and visual i