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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection X 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181497 11 /21 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) SRH Business Site Address City ZIP Code 749 E CHARTER WAY STOCKTON 95206 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 , PhikTite & 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 3 TANK ID : (By tank number, storedproduct, etc.) 87 91 DSL What is the tank inside diameter? (Inches) 96 96 96 Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) oPw oPw OPW 61SO 61SO 61SO 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 ❑ Restricts Flow ❑ Restricts Flow ❑ AN Alarm ❑ AA/ Alarm ❑ AN Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes N No ❑ Yes ❑x No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 80 80 1 /2 801 /2 What is the percent capacity of the tank at which the overfill prevention equipment activates? 92 93 93 Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑ 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 x❑ Pass gjaiiij 0 Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional commeav also be provided here. AECEIVED JUN % VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accor r dv Q Regulations , Title 23 , Division 3 , Chapter 16, Section 2637 . 2 and all the information contained here n iis�� C ' v I n AL I H UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, A/V = Audible and Usual