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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair inspection R 36 Month Inspection <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 113/2019 <br /> Business Name (Same as Facility Name orDBA•Doing Business As) <br /> Arco 2186 <br /> Business Site Address City ZIP Code <br /> 3212 N California Stockton 195204 <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 /> David Rouse 1 (925) 551 -4777 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6!28/2026 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications ) V V� f <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑ Manufacturer Guidelines (Specify) : <br /> Used. <br /> Qx Industry Code or Engineering Standard (Specify) Tank charts , OPW Manual , Tape measure <br /> El Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> pq <br /> TANK IDs (By tank number, storedproduct, etc.) T1 - Unleaded T1 - Unleaded TMnleaded T3-Premium <br /> What Is the tank Inside diameter? (inches) 120 120 120 120 <br /> Is the fill piping secondarily contained? Q Yes [:1 No EQ Yes [] No (x) Yes O No (] Yes C] No <br /> Is the vent piping secondarily contained? ❑ Yes 0 No 0 Yes [E No 0 Yes I] No 0 Yes [] No <br /> Overfill Prevention Equipment Manufacturer(s) OPW 7150 OPW 7150 OPW 7150 OPW 7150 <br /> i <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? [] Restricts Flow Q Restricts Flow [] Restricts Flow [] Restricts Flow <br /> (Check all that apply. ) <br /> ❑ AN Alarm 0 A/V Alarm ❑ AN Alarm [I AN Alarm <br /> Are flow restrictors installed on vent piping? 0 Yes F!] No 0 Yes [] No ❑ Yes I] No 0 Yes (] No <br /> At what level in the tank is the overfill prevention set 107 107 1063 /8 1061 /2 <br /> to activate? (inches from bottom of tank ) <br /> What is the percent capacity of the lank at which the <br /> overfill prevention equipment activates? 95 95 95 95 <br /> Is the overfill prevention in proper operating condition Yes Q Yes 21 Yes 9 Yes <br /> to respond when the substance reaches the <br /> appropriate level? D No (Specify in V) 0 No (Specify in V ) ❑ No (Specify In V ) [3No (Specify in V) <br /> IV, SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 0 Pass © Fail Q Pass ❑ Fail El Pass ❑ Fail E] Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fait" 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 equipment was Inspected in accordance with California Code of Regulations , Title 23, <br /> Division 3 , Chapter 16, Section 2637. 2 and all the Vforni contained herein Is accurate . <br /> UST Service Technician Signature <br /> I f the facility has more components W this form accommodates, additional copies of this page may be attached. <br /> CERS = California Ernirorvnental Reporting System. 113 = Identification. UST = Underground Storage Tank, ICC = International Code Council. AN = Audible and Visual <br />