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I� UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181669 6/ 11 /2019 Business Name (Same as Facility Name or DBA-Doing Business As) QUICK SHOP # 1 Business Site Address City ZIP Code 2072 YOSEMITE AVE MANTECA 95337 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) Phone # David Winkler (209 ) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 Ex . 3/31 /2020 8883059-UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications) FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 3- 14-2020 Emco #3207 Ex . 11 /16/20 ATG : VR : B34975 ATG : 2/8/20 INCON 1009853708 Ex. 11 /30/2020 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify): Used : REMOVED OPW DROP TUBES ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 2 TANK ID : (By tank number, stored product, etc.) 87- 1 91 100 110 What is the tank inside diameter? (Inches) 95 . 75 95 . 75 95 . 75 95 . 75 Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes 0 No Is the vent piping secondarily contained? ❑ Yes (E No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes 9 No Overfill Prevention Equipment Manufacturer(s) oPw oPw OPW 61 SO 61 SO 61 SO What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow x❑ Shuts Off Flow ❑ Shuts Off Flow when activated? ❑ (Check all that apply.) ❑ Restricts Flow Restricts Flow E] Restricts Flow E] Restricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes IE No ❑ Yes R No ❑ Yes ❑X No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 84 . 5 84 . 5 85 . 5 85 What is the percent capacity of the tank at which the overfill prevention equipment activates? 93 93 94 93 Is the overfill prevention in proper operating condition ❑K Yes ❑x Yes 0 Yes ❑x 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 ❑Q Pass ❑ Fail ❑x Pass ElFail 0 Pass E] 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 ^ 7 If the facility has more components than this form accommodates, additional copies of this page maybe attached. CERS = Calffomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, [CC = International Code Council, AN = Audible and Usual