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If the facility has more components than this form accommodates, additional copies of this page may he attached. <br />,ERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = Intemalional Code Council, <br />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 <br />10180943 <br />Date of Overfill Prevention Equipment Inspection <br />2/5/2019 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />SHOP N GO <br />Business Site Address <br />4511 PACIFIC AVE <br />City <br />STOCKTON <br />ZIP Code <br />95207 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) <br />David Winkler <br />Phone # <br />1 (209) 744-0112 <br />Contractor / Tank Tester License # <br />08-1739 Ex.3/31/2020 <br />ICC Certification # <br />8883059-UT <br />ICC Certification Expiration Date <br />1/29/2020 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />FF- EBW , PhikTite & EVR Phase 1 1009853708 Ex 11/29/20 OPW 104-633 Ex 3-14-2020 <br />Emco #3207 Ex. 11/16/20 ATG: VR: B34975 ATG: 2/8/20 INCON 1009853708 Ex.11/30/2020 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />❑x Manufacturer Guidelines (Specify): <br />REMOVED OPW DROP TUBES <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. —T# <br />-of Attached Pages 5 <br />TANK ID: (By tank number, stored product, etc.) <br />87 <br />91 <br />What is the tank inside diameter? (Inches) <br />96 <br />96 <br />Is the fill piping secondarily contained? <br />❑ Yes 0 No <br />❑ Yes 0 No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes Eid No <br />❑ Yes Z No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW <br />OPW <br />61 SO <br />71 SO <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />0 Shuts Off Flow <br />❑ Restricts Flow <br />❑ A/V Alarm <br />X Shuts Off Flow <br />El Restricts Flow <br />❑ A/V Alarm <br />❑ Shuts Off Flow <br />❑Restricts Flow <br />❑ A/V Alarm <br />❑ Shuts Off Flow <br />❑Restricts Flow <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes ❑x No <br />❑ Yes ❑x No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />82 <br />863/4 <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />91 <br />95 <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />❑x Yes <br />❑ No (Specify in V.) <br />❑x Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />R Pass ❑ Fail <br />I I] Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ 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 />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I hereby certify that the overfill prevention equipmentwas 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 V <br />AN =Audible and Usual <br />