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t UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection 1 . FACILITY INFORMATION CERS ID 10181237 Date of Overfill Prevention Equipment Inspection 19/26/ 18 Business Name (Same as Facility Name or DBA-Doing Business As.) WOODBRIDGE AMPM Business Site Address City ZIP Code 18860 LOWER SACRAMENTO RD WOODBRIDGE, CA 95258 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # DAVE WINKLER 209 744 - 0112 Ext. Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 8883059-UT 1 - 31 -20 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 Used : M Manufacturer Guidelines (Specify) Removed Drop Tubes ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages : 3 Tank ID : (By tank number, stored product, etc.) 87 91 DSL What is the tank inside diameter? (Inches) 96 96 96 Is the fill piping secondarily contained ? [3d Yes ❑ No M Yes ❑ No [M Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ® Yes ❑ No M Yes ❑ No M Yes ❑ No ❑ Yes ❑ No OPW OPW OPW Overfill Prevention Equipment Manufacturer(s) 6150 61S0 61S0 What is the overfill prevention equipment [9 Shuts Off Flow IN Shuts Off Flow $] Shuts Off Flow ❑ Shuts Off Flow response when activated ? ❑ Restricts Flow ❑Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑ AN Alarm ❑ AN Alarm ❑ AIV Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes M No ❑ Yes M No ❑ Yes M No ❑ Yes ❑ No At what level in the tank is the overfill prevention 79 . 75 80 . 5 set to activate? (Inches from bottom of tank.) 81 What is the percent capacity of the tank at which 94 95 95 the overfill prevention equipment activates? Is the overfill prevention in proper operating ® Yes [X Yes [ Yes ❑ Yes condition to respond when the substance ❑ No ❑ No ❑ No ❑ No reaches the appropriate level? (Specify in section V.) L (Specify in section V.) (Specify in section V.) (Specify in section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass E] Fail M Pass E] Fail L$ Pass El Fail ❑ Pass ElFail V. COMMENTS All items marked Fail' must be explained in this section. Any additional comments may also be provided here, r r7 f11 G r �W100NM _ � 1 1s i tt VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THISy1NSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.2 and all the information contained herein is accurate. 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