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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 0 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10411900 5/7/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Speedway 6187 <br /> Business Site Address City ZIP Code <br /> 2705 Country Club Stockton 95204 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Kris Bell (408)971-2445 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8833000 10/29/21 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> F.F.#1004933708 <br /> OPW#902968 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method 0Manufacturer Guidelines(Specify):UseFranklin Fueling <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 1 <br /> TANK ID: (By tank number,stored product,etc.) 1-Regular 2-Premium 3-Diesel <br /> What is the tank inside diameter?(Inches) 96" 96" 96" <br /> Is the fill piping secondarily contained? ❑✓ Yes ❑ No 0 Yes ❑ No ❑Q Yes ❑ No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? 0 Yes ❑ No ❑✓ Yes ❑ No 0 Yes ❑ No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Frankling Fueling Frankling Fueling Frankling Fueling <br /> EBW EBW EBW <br /> What is the overfill prevention equipment response 0 Shuts Off Flow 0 Shuts Off Flow 0 Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) ❑ ❑ ❑ <br /> Restricts Flow Restricts Flow Restricts Flow Restricts Flow <br /> ❑AN Alarm ❑A/V Alarm ❑A/V Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 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.) 86" 89.75" 87.75" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 0.9448% 0.9723% 0.9583% <br /> Is the overfill prevention in proper operating condition 0 Yes ❑Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No(Specify in V.) 0 No(Specify in V.) 0 No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ✓❑ Pass ❑FaIF11 ❑ Pass ✓❑ Fail ❑ Pass 0 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 /> Both Premium and Diesel Overfill are set above 95%-Failures. <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 <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,AI/=Audible and Visual <br />