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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) <br /> Type of Action ❑x Installation Inspection ❑x Repair Inspection ❑x 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 17931001 12/10/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> 7-Eleven #2369-32190 <br /> Business Site Address CityZIP Code <br /> 4943 S CA-99 Stockton 95215 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Ismael Rios (916) 372-1888 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 617238 8176672 3/6/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Phase 1 UST Enhanced Vapor Recovery Tech Number#103926 Rj= ,q <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INF ` <br /> Inspection Method ❑x Manufacturer Guidelines(Specify). <br /> Used: OPW Install & Maintenance Guidelines DEC 1 0 2018 <br /> ❑Industry Code or Engineering Standard(Specify): <br /> E]Engineered Method (Specify): H <br /> DEPARTMENT <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID:(Bytanknumber,stored pmduct etc.) Tank- 5 (89) <br /> What is the tank inside diameter?(Inches) 89.75 <br /> Is the fill piping secondarily contained? Z Yes ❑No ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑ No <br /> Is the vent piping secondarily,contained? 0 Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) dPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) ❑ <br /> Restricts Flow Restricts ❑ ❑ <br /> Flow Restricts Flow Restricts Flow <br /> ❑AN Alarm ❑AA/Alarm ❑AA1 Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes ❑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.) 81.75 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑Yes El Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No(Specify in V) E01No(Specify in V.) ❑No(Specify in V.) ❑ No(Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 9 Pass ❑Fail 11 ❑ Pass ❑ Fail 11 ❑ Pass ❑Fail ❑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 ! rr <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council,AN=Audible and visual <br />