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W . O . # NW1 - 2338329 <br /> 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 10165823 Date of Overfill Prevention Equipment Inspection <br /> 9/19/2018 <br /> Business Name (Same as 1`66ft Name or DBMDoing ftshess As) <br /> 7-Eleven #17647 <br /> Business Site Address CRY ZIP Code <br /> 1048 W Yosemite Ave. I Manteca 95336 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Hint as shown on the ICC Certification.) Phone # <br /> Darren Sciume (800) 964-0010 <br /> Contractor I Tank Tester Ucense # ICC Certification # ICC Certification Boration Date <br /> 743160 8223550 5/27/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable cardf cadorm) <br /> OPW Phase 1 UST EVR <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify): OPW <br /> Used: <br /> ❑ Industry Code or Ergirheering Standard (Specify): <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine Cyte results. # of Attached Pages 1 <br /> TANK ID* (By tank number, stored product, etc.) T1 : RUL T2: PUL <br /> What Is the tank Inside diameter? (Inches) 89.75 89.75 <br /> Is the fill piping secondarily contained? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes 0 No ❑ Yes 0 No <br /> [I Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> What is the overfill prevention equipment response 0 Shuts OK Flow ® Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow realrictors installed on vent piping? ❑ Yes 0 No ❑ Yes 0 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) 80.5 80 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% 95% <br /> Is the overfill prevention in proper operating condition M Yes ® Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify V.) ❑ No (Specify in V) ❑ No (Specify In V.) ❑ No (Specify in V.) <br /> N. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail I ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fall <br /> V. COMMENTS <br /> Any items marked Fali ' 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 /> 1 herebtCr <br /> erfill prevention equipment was Inspected in accordance with California Code of Regulations, Title 23, <br /> Divisioction 2631.2 and ail the Information contained herein is accurate. <br /> UST Seture <br /> naKs than this torr aeeammodabs, additional copies of Otis page may be attached <br /> CERS allitimeie <br /> = C011110MM ReporlltvSyslerm 0 = 16ordicallorii UST = Underground! SlorapeTardclCC = tbrtafondCode Coud IW=Ahleand Vlaral <br />