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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181355 3/2/20 Business Name (Same as Facility Name or DBA-Doing Business As) TIWANA GAS Business Site Address City ZIP Code 1210 E HAMMER LANE STOCKT ) N 95210 Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) Phone # Edward Stearns (209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 14- 1760 Ex . 09/30/2020 8883080-UT 11 /9/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications) FF- EBW , PhikTite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3- 14-2020 Emco 3205 Ex . 11 / 16/2020 ATG : VR A31048 Ex . 8/9/ 19 Incon 1009893708 11 /30/2020 III . OVERFILL PREVENTION EQUIPMENT II PECTI'QN IN OR NATMI in Inspection Method p Manufacturer Guidelines (Specify): REMOVE AND INSPECT . . Used : ❑ industry Code orEngineering Standard (Specify) : PR ❑ Engineered Method (Specify) : r „ # of Attdctied rages Attach the inspection procedures and all documentation required to determine the results i F 2 TANK ID : (By tank number, stored product, etc.) 87 89 91 What is the tank inside diameter? (Inches) 127 , 50 127 . 50 127 . 50 Is the fill piping secondarily contained ? ❑x Yes ❑ No El Yes ❑ No N Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes EINo ❑ Yes 9 No ❑ Yes ❑x No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) FRANKLIN FUELNG FRANKLIN FUELING FRANKLIN FUELING DEFENDER DEFENDER DEFENDER What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow M Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) E] Restricts Flow ElRestricts Flow ❑ Restricts Flow ElRestricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? ❑ Yes E No ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No At what level in the tank is the overfill prevention set 108 . 5 109 . 5 109 . 5 to activate . (Inches from bottom of tank.) What is the percent capacity of the tank at which the i overfill prevention equipment activates? SIM 91 . 3 91 . 3 i i Is the overfill prevention in proper operating condition ❑x Yes 9 Yes Z Yes ❑ Yes to respond when the substance reaches the i appropriate level ? ElNo (Specify in V.) ElNo (Specify in V) ElNo (Specify in V) ElNo (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Pass ❑ Fail ZPass E] Fail Pass ❑ Fail ❑ Pass El 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 equipmentwas 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 E` If the facility has more components than this form accommodates, additional copies of this page may be attached. j' CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl, AN = Audible and Usual C