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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 ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181491 1 / 11 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> MARKS FOOD & FUEL <br /> Business Site Address ity 95240 <br /> 880 E VICTOR RD <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 /> Edward Stearns (209 ) 744-0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 14- 1760 Ex . 09/30/2020 8883080-UT 11 /9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3- 14-2020 <br /> Emco 3205 Ex . 11 / 16/2020 ATG : VR A31048 Ex . 8/9/ 19 Incon 1009893708 11 /30/2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : REMOVE AND INSPECT OPW <br /> Used : <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 DIESEL <br /> What is the tank inside diameter? (Inches) 1173/4 7117 3/4 96 <br /> Is the fill piping secondarily contained? ❑ Yes n No ❑ Yes El NoT�DYes Yes Z No ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes N No ❑ Yes EINo ❑ Yes 0 No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> 71SO 71SO 61SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow (] Shuts Off Flow 0 Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes Z No ElYes N No ElYes ❑ No ElYes E] No <br /> At what level in the tank is the overfill prevention set 105 103 86 <br /> to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the 94 $ 93 . 6 94 . 4 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition ❑x Yes Z Yes Z Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? El No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) EI No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 0 Pass ❑ Fail 9 Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS _ a r, <br /> Any items marked "Fail' must be explained in this section. Any additional comments maillai o ie p ovrde here <br /> 14 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDU T,1 . <br /> hereby certify that the overfill prevention equipment was inspected in accordance with Califopm, gofle of, Rtegplations , Title 23 , <br /> Division 3 , Chapter 16, Section 2637. 2 and all the information contained herein is accurate. ` <br /> 10 <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> ode Council, AN = Audible and usual <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International C <br />