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Jan. 21. 2019 3: 12PM Qonlee Pump Co No. 1358 P. 2 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(page t ot1) <br /> Type of Action ❑Installation Inspection Repalr Inspection ❑16 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> _ 1/16/2019 <br /> Business Name(Sane as Facility Name or DBA-Polrtg Business As) <br /> Escalon Mini Mart <br /> Business Site Address city ZIP Code, <br /> 1097 E. Yosemite Ave. . Escalon 95320 <br /> �v I). UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Catt87catfon:) Phone# <br /> Miguel Zaragoza 1 (209) 537-9396 <br /> Contractor/Tank Tester I-lcanse# ICC Cortlflcatlon# ICC Certification Expiration Date <br /> 6216444 8/4/2019 <br /> Overfill Prevention Equipment Inspecllon Training and Certifications Gist applicable certifications,) <br /> OPW #175405 Franklin Fueling #2996953702 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used. <br /> ❑Industry Code or Engineering Standard(Specify): <br /> El Engineered Method(Specify): <br /> Attach the Inspection procedures and all documentation required to determine the results, #of Attached Pages <br /> TANK ID;(Hy(anknumber,stored product,etc) 91 <br /> What Is the lank Inside diameter?(Inches) 111 <br /> is lho fill plping secondarily contained? ❑Yes ®No ❑Yes ❑Nq 0 Yes D No C]Yes ❑No <br /> Is the vent piping secondarily oonlalned? D Yes M No ❑Yes ❑No ❑Yes ❑No D Yes ❑No <br /> Overfill Prevention Equipment Manuracturer(s) PhilTite-Franklin <br /> Defender Series <br /> What Is the overfill prevention equipment response D Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check althatapply.) ❑Restricls Flow Restricts Flow ❑Restricts Flow D Restricts Flow <br /> ❑AN Alarm D AN Alarm D AN Alarm LI All/Alarm <br /> Are tlowresiriclors Installed on vent piping? ❑Yes ONO D Yes D No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set J v <br /> to activate?(inches from bottom of fank) 100 1/8 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% <br /> Is the overfill prevention in proper operating condition I]Yes El Yes ❑Yes D Yes <br /> to respond when Ilia substance reaches tno <br /> appropriate level? w ❑No(Specifyin V) ❑No(Sp00/Jn V) D No(specify in V.) ❑No(Specify in V) <br /> IV, SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Q Pass D Fail ❑Pass ❑Fa11 D Pass ❑Fatt 0 Pass D 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 thatthe overflll prevention equipmentwas Inspected In accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 an II the Information contained herein is accurate. <br /> UST Service TechnIcIan Signature ,r b L 0 <br /> If the facility has mora components than this form accolwodaWs,additional copies of this page may be attached. <br /> CERS=Catform Emirartrnenid Reporitng*Aa a,ID�Identification.LAST=Unde Lound storage Tank ICC=Inte,nakinal Coyle C..otNd,AN-Amble and visual <br />