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I UNDERGROUND STORAGE INFORMATION AN ENTAIL HEALTH Facility Name or Dt3A-Doing Business As) Date of Overfill Prevent Quik Stop #76 Business Site Address City ZIP Code 1030 S. Olive Stockton 95215 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Cerlification.) Phone # Juan Jauregui (916) 889-3897 Contractor If Tank Tester License # ICC Certification # ICC Certification Expiration Date 5246964 8/30/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Phase 1 EVR - Cert # 100580 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method (� Manufacturer Guidelines (Specify): Used: ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Meihorl (Specify): Attach the inspection procedures and all documentation required to determine the results. TANK ID: (By tank number, stored product, r?tc.) What is the tank inside diameter? (Inches) Is the fill piping secondarily contained? Is the vent oioino secondariiv contained? Overfill Prevention Equipment Manufacturers) What is the overfill prevention equipment when activated? (Check all that apply.) Are on vent asoline 87 G - 89 3/4" Q Yes El No Yes [:1 No IiIlV Gasoline 91 i - 893/4 11 Q Yes ❑ No Yes ElNo OPW A ❑ Shuts Off Flow � Restricts Flow ❑ V Alarm ❑ Yes F71No ❑Yes ❑Yes # of Attached Pages ❑ No ElYes ElNo ❑ No ElYes ElNo ❑ Shuts Off Flow ❑ Restricts Flow ❑ A(V Alarm ❑Yes ElNo ❑ Shuts Off Flow ❑ Restricts Flow ❑ AN Alarm ❑Yes ElNo At what level in the tank is the overfill preventi��n set to activate? (Inches from bottom of tank.) 801/2 801/2 If What is the percent capacity of the tank at which the overfill prevention equipment activates? 95% 95% Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑ 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 ❑x Pass ❑ Fail Z Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Faii 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 1 hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2,637.2 and all the information contained herein is accurate. !f the facility has m re com nents tha tis for accommodates, additional copies of this page maybe attached. CERS = CaCdornia Envir ment R rung Sys+ D = identification, UST =Underground Storage Tank, ICC = International Code Counal, AN =Audible and Visual C..