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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Paget oft) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection 0 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Dale of Overfill Prevention Equipment Inspection <br /> Business Name(Sa9/26/2018 <br /> me as Facility Name or DBA-Doing Business As) <br /> Quik Stop #120 <br /> Business Site Address City ZIP Cotle <br /> 9321 Thornton Rd Stockton 95207 <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 /> Juan Jaure ui (916) 889-3897 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 5246964 8/30/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Phase 1 EVR -Carl# 100580 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method (]Manufacturer Guidelines(Specify): <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineeretl Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID:(By tank number,stored product,etc.) Gasoline - 87 Gasoline - 91 <br /> What is the tank inside diameter?(Inches) 89 3/4" 89 3/4" <br /> Is the fill piping secondarily contained? I]Yes ❑No .❑Yes ❑No —6 Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑. Yes []No ❑* Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW DPw <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow —0 Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) 2)Restricts Flow ❑x Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑AN Alarm ❑A/V Alarm ❑AIV Alarm ❑AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes (]No ❑Yes No ❑Yes Cl No ❑Yes El No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 80 1/2" 80 1/2" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% 95% <br /> Is the overfill prevention in proper operating condition ❑z Yes ❑x Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V) ❑No(Specify in V) ❑No S eci in V. <br /> ( p fY ) ❑No(Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑Fail 19 Pass ❑Fail I ❑Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fair 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 ceotherfill prevention equipmentwas Inspected in accordancewith California Code of Regulations,Title 23, <br /> Division 3, on 2637.2 and all the information contained herein is accurate. <br /> UST Service r '-If the lata/ he is f n t is form accommodates,additional copies of this page may be attached. <br /> CERS=C 'ng System,ID=klenfification,UST=Underground Storage Tank,ICC=International Code Council,AA/=Audble and Vsual <br /> 4 <br />