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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 x❑ 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181317 4/4/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> ESTES <br /> Business Site Address City ZIP Code <br /> 7611 S AIRPORT WAY STOCKTON 99520 <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 ❑x Manufacturer Guidelines (Specify) : <br /> Used : OPW REMOVE DROP TUBE <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 3 <br /> TANK ID : (By tank number, storedproduct, etc.) DIESEL <br /> What is the tank inside diameter? (Inches) 89a75 <br /> Is the fill piping secondarily contained ? ❑ Yes Fx1 No ❑ Yes LINO ❑ Yes LINO ❑ Yes LINO <br /> Is the vent piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) opw <br /> 6i so <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑ 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 /> ❑ A/V Alarm ❑ A/V Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? x❑ Yes ❑ No ❑ Yes ❑ 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.) 77 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates ? 91 % <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑ 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 N Pass ❑ Fail 1 ❑ Pass ❑ Fail ❑ 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 /> REQ D <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTINGINI'S1NSPECTION <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 a We,,,, <br /> UST Service Technician Signature (1 1 <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />