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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of i ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181238 7/ 15/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Arco#5450 Business Site Address City ZIP Code 1617 W . Fremont Stockton 95203 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # David Rause (925 ) 551 -7555 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 220793 8292530 6/28/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications ) OPW Tech Cert . #0108211 Exp . 3/8/2021 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method 0 Manufacturer Guidelines (Specify) Used Tank Chart, OPW manual , Tape Measure ❑ Industry Code or Engineering Standard {Specify) ❑ Engineered Method (Specify) . Attach the Inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc ) TA 871M T-2 87/AUX T-3 91 What is the tank inside diameter? (Inches) 92 92 92 Is the fill piping secondarily contained? 0 Yes ❑ No El Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes JE No ❑ Yes 2 No ❑ Yes 0 No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW What Is the overfill prevention equipment response Shuts Off Flow 0 Shuts Off Flow 0 Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply ) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ A/V Alarm ❑ AIV Alarm ❑ AN Alarm ❑ AIV Alarm Are flow restriclors installed on vent piping ? ❑ Yes 0 No ❑ Yes [E No ❑ Yes 0 No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 80 3/8 " 84 " 84" What is the percent capacity of the tank at which the overfill prevention equipment activates? 93 % 96 % 96 % Is the overfill prevention in proper operating condition 0 Yes ❑ Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V) 0 No (Specify in V.) 0 No (Specify in V ) ❑ No (Specify In V.) IVa SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑ Fail ❑ Pass x❑ Fail ❑ Pass 0 Fail ❑ Pass ❑ Fall V . COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here T-2 87/Aux , & T-3 91 failed overfill prevention . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was spected in accordance with California Code of Regulations , Title 23, Division 3, Chapter 16, Section 2637. and all th nfo tAlon contained herein is accurate. UST Service Technician Signature if the facility has more components t an thls form accommodates, additional copies of this page may be attached, CERS = CaJiforria Environmental Reporting System, ID = Identification. UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual