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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection x❑ 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180593 10/ 11 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) MONTEREY FUELING Business Site Address TMANTECA ity ZIP Code 1001 E YOSEMITE AVE CA 95336 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) TVhone # David Winkler 1 (209 ) 744- 0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 8883059 - UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 104-633 Ex 3- 14-2020 Emco #3207 Ex . 09-21 -2020 VR : B34975 ATG : 2/8/20 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : REMOVED DROP TUBES - OPW ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 5 TANK ID : (By tank number, storedproduct, etc.) 87 91 DSL What is the tank inside diameter? (Inches) 92 92 92 Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes R No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes [E No ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW 61SO 61SO 61SO What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated ? (Check all that apply.) El Restricts Flow ❑ Restricts Flow El Restricts Flow El Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes (] No ❑ Yes N No ❑ Yes H No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 821 /2 821 /2 91 What is the percent capacity of the tank at which the 95 99 overfill prevention equipment activates? 95 Is the overfill prevention in proper operating condition ❑x Yeses YEl Yes El Yes to respond when the substance reaches the appropriate level ? ElNo (Specify in V.) ❑ No (Specify in V) ❑x No (Specify in V.) El (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑ Fail I ❑x Pass ❑ Fail ❑ Pass Z Fail ❑ Pass ❑ Fail V. COMMENTS mp Any items marked "Fail' must be explained in this section. Any additional comments may 'd/sotbO provided 00 DSL DROP TUBE FLAPPER IS TOO HIGH . NEEDS REPLACED ASAP ',j 0 2i11 �1 .� A'( VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUg I kTAI I E, I hereby certify that the overfill prevention equipmentwas inspected in accordance WO a i orrnia_4 =or e'Qf qgu afions, Title 23, Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate . 1 ) \ - I i '' I UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Visual I I