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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel of 1) Type of Action ❑ Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10118074 1/29/2019 Business Name(Same as Facility Name or DBA-Doing Business As) COUNRTY CLUB FUEL Business Site Address CityZIP Code 2575 COUNTRY CLUB BLVD STOCKTON 95204 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Felix Ramirez (209) 744-0112 Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date 08-1740 Ex. 03/31/2020 8883072-UT 11/9/2020 Overfill Prevention Equipment Inspection Training and Certifications(List applicable cert cations.) FF- FF- EBW, Phil-Tite & EVR Phase 1 1009883708 EX 11-29-20 DPW 104-634 Ex 3-14; Emco 3147 Ex. 11-16-20 VR: B34976 ATG: 7/7/20 Incon 1009883708 Ex 11-30-20 101 EW III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMAYM Inspection Method ❑x Manufacturer Guidelines(specify). Used: VEEDER ROOT REMOVE PROBES FEB 0 5 2019 ❑Industry Code or Engineering Standard(Specify): ENVIRONMEN- ❑Engineered Method(Specify): TW T Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 5 TANK ID: (By tank number,stored product,etc.) 87 91 DIESEL What is the tank inside diameter?(Inches) 114 114 114 Is the fill piping secondarily contained? p Yes ❑No Yes ❑No ❑x Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? E Yes ❑No p Yes ❑No p Yes ❑No ❑Yes ❑ No Overfill Prevention Equipment Manufacturer(s) VEEDER VEEDER VEEDER ROOT ROOT ROOT What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activated? (Check all that apply.) ❑Restricts Flow El Restricts Flow ElRestricts Flow L1 Restricts Flow ❑x AN Alarm ❑x AN Alarm ❑x AN Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes 2 No ❑Yes [9 No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 96 96 96 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90% 90% 90% Is the overfill prevention in proper operating condition p Yes Z Yes El Yes ❑Yes to respond when the substance reaches the appropriate level? ❑No(Specify in V) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑Fail I ❑x Pass ❑Fail 1 0 Pass ❑Fail ❑ Pass ❑Fail V. COMMENTS Any items marked"Fail"must be explained in this section. Any additional comments may also be provided here. 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 U ' If the facility has more components than this form accommodates,additional copies of this page maybe attached. CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,A.N=Audible and Visual