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f i t7 <br /> lili 142 123:11: :111 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ED 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181293 4/4/2019 <br /> Business Name (Same as Facility Name or DBA -Doing Business As) <br /> GRUPE COMMERCIAL <br /> Business Site Address City ZIP Code <br /> 5000 LINDBERGH STREET STOCKTON 95206 <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 I 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 , Phil -Tite & 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, stored product, etc.) JET A <br /> What is the tank inside diameter? (Inches) 92 <br /> Is the fill piping secondarily contained ? ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes Fxl No ❑ Yes ❑ No ❑ Yes ❑ No <br /> El Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s ) OPW <br /> 61 SO <br /> What is the overfill prevention equipment response 9 Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) ❑ ❑ ❑ <br /> Restricts Flow Restricts Flow Restricts Flow Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping? ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set 82 <br /> to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94% <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.) [INo (Specify in V.) ElNo (Specify In V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results E9 Pass ❑ Fail ❑ 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was 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 accurate . <br /> UST Service Technician Signature <br /> t ,If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Callbmia Environmental Reporting System, ID = Identification, UST =' `Underground Storage Tank, FICC = International Code Council, AN = Audible and Usual <br />