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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page -I of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection 9 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181081 9/3/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> FOOD MART GAS Report 1 of 2 <br /> Business Site Address City ZIP Code <br /> 2185 EAST FREMONT STREET STOCKTON 95205 <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 /> Felix Ramirez (209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1740 Ex . 03/31 /2020 8883072-UT 11 /9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- FF- EBW , PhikTite & EVR Phase 1 1009883708 EX 11 -29-20 OPW 104-634 Ex 3- 14-2020 <br /> Emco 3147 Ex . 11 - 16-20 VR : B34976 ATG : 7/7/20 Incon 1009883708 Ex 11 - 30-20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Nx Manufacturer Guidelines (Specify) : VEEDER ROOT <br /> Used : <br /> Nx Industry Code or Engineering Standard (Specify) : Floats <br /> ❑ Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 <br /> TANK ID : (By tank number, stored product, etc.) 87 91 DIESEL <br /> What is the tank inside diameter? (Inches) 113 . 75 113 . 75 113 . 75 <br /> Is the fill piping secondarily contained ? N Yes ❑ No I] Yes ❑ No R Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑x Yes ❑ No ❑x Yes ❑ No ❑X Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) VEEDER VEEDER VEEDER <br /> ROOT ROOT ROOT <br /> What is the overfill prevention equipment response N Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑x A/V Alarm ❑x A/V Alarm N A/V Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping ? xN Yes ❑ No 0 Yes ❑ No N Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 96 96 96 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 % 90 % 90 % <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes Z Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Z Pass ❑ Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail =E1 ss ❑ 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 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Cafdomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />