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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 Z 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10180727 4/9/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> SAVE ON FUEL <br /> Business Site Address City ZIP Code <br /> 420 W YOSEMITE MANTECA 95336 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) Phone # <br /> David Winkler (209 ) 744 - 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 3- 14-2020 <br /> Emco #3207 Ex . 11 / 16/20 ATG : VR : B34975 ATG : 2/8/20 INCON 1009853708 ExA 1 /30/2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : REMOVED OPW DROP TUBES <br /> ❑ Industry Code or Engineering Standard (Specify) : <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 <br /> What is the tank inside diameter? (Inches) 89 . 75 90 . 41 <br /> Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> 61 so 61 SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes N No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 79 79 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93 . 7 92 . 9 <br /> Is the overfill prevention in proper operating condition ❑x 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 (Specify in V.) ❑ No (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results z Pass ❑ Fail ❑x Pass ❑ Fail 11 ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section . Any additional comments may also be provided, here. <br /> 11 F <br /> Lj� . ;p <br /> OCT 9- 019 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTNG . THIS INSPECTION <br /> 1 herebycertifythat the overfill prevention equipment was ins ected in accordance with alifornia(Cdde of Re ulai <br /> ottitle 23 <br /> , <br /> Division 3 , Chapter 16, Section 2637. 2 and all the information contained herein is accurate. <br /> UST Service Technician Signature V <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />