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6 <br /> UNDERGROUNDSTORAGETANK <br /> F� OVERFILL 'PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action Installation Test F, Repair Test 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection : <br /> 10165815 9/23/2020 <br /> Business Name ( Same as Facility Name or DBA- Doing Business As . ) <br /> 7-ELEVEN # 17334 MKT 2368 ( N -747 ) <br /> Business Site Address City: Zip : <br /> 4501 N . PERSHING AVE . @ ROSEMARIE LN . STOCKTON 95207 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification . ) Phone # <br /> Jesus Saldivar ( 800 ) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 8361393 6/13/2021 <br /> Spill Container Testing Training and Certifications (List applicable certifications. ) <br /> ICC - CA UST Service Technician 8361393 06/13/2021 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> F Manufacturer Guidelines (Specify) <br /> Test Method Used : F' Industry Code or Engineering Standard (Specify) PEI RP 1200 <br /> F Engineered Method (Specify) <br /> Attach the testing procedures and all documentation required to determine the results. # of Attached Pages : <br /> 1 <br /> Tank ID : (By tank number, stored product, etc.) T-2 <br /> What is the tank inside diameter? ( Inches ) 96 . 00 in . <br /> Is the fill piping secondarily contained ? F Yes r' No r Yes r No F Yes F' No F Yes F No <br /> Is the vent piping secondarily contained ? F Yes (� No F Yes F No r Yes F No r Yes r No <br /> Unknown <br /> Overfill Prevention Equipment Manufacturer(s) <br /> OPW <br /> What is the overfill prevention equipment response F. Shuts Off Flow Shuts Off Flow Shuts Off Flow r Shuts Off Flow <br /> when activated ? (Check all that apply . ) Restrict Flow Restrict Flow Restrict Flow Restrict Flow <br /> A/V Alarm AA/ Alarm AA/ Alarm AA/ Alarm <br /> Are flow restrictors installed on vent piping ? F Yes r No r Yes F No r Yes r No r Yes r No <br /> At what level in the tank is the overfill prevention set to 86 . 5 <br /> activate? ( Inches from bottom of tank . ) <br /> What is the percent capacity of the tank at which the 94 , 8 <br /> overfill prevention equipment activates ? <br /> Is the overfill prevention in proper operating condition 17 Yes F Yes r Yes Yes <br /> to respond when the substance reaches the r No F No r No r No <br /> appropriate level ? (Specify in section V) (Specify in section V) (Specify in section V) (Specify in section V) <br /> fV. SUMMARY OF TESTING RESULTS <br /> Overfill Prevention Inspection Results r Pass r Fail Pass r Fail r Pass r Fail=Pass Pass Fail <br /> V. COMMENTS <br /> All items marked failed above must be explained in this section . Any additional comments may also be provided here . <br /> couldnt test req riser due to drop tube stuck to the nipple . <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations , title 23 , division 3 , chapter 16 , section <br /> 2637 . 1 and all the information contained herein is accurate . <br /> UST Service Technician Signature <br /> 4�4w 4z <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 <br />