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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181585 4/11/19 Business Name (Same as Facility Name or DBA -Doing Business As) WATERLOO LIQUORS Business Site Address City ZIP Code 2512 E WATERLOO RD STOCKTON 95219 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Edward Stearns (209) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 14-1760 Ex. 09/30/2020 8883080 -UT 11/9/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11/29/2020 OPW 104-635 Ex 3-14-2020 Emco 3205 Ex. 11/16/2020 ATG: VR A31048 Ex.8/9/19 Incon 1009893708 11/30/2020 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method [E Manufacturer Guidelines (Specify): Used: REMOVE AND INSPECT 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, stored product, -etc.) 87 91 DIESEL What is the tank inside diameter? (Inches) 114 96 96 Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes I] No ❑ Yes ❑x No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes Z No ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW 61S0 61S0 61S0 What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow Z Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) El Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ AfV Alarm Are flow restrictors installed on vent piping? n Yes ❑ No ❑x Yes ❑ No x❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 102.2 86.3 86 What is the percent capacity of the tank at which the 94 94 94 overfill prevention equipment activates? Is the overfill prevention in proper operating condition ❑x Yes Z Yes Z Yes Eoi to respond when the substance reaches the ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) V) appropriate level? IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑Q Pass El Fail Z Pass El Fail ❑x Pass El ail ❑Pass F1 Fail V. COMMENTS Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. f7 -_ I1PR 2 VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION � hereby certify that the overfill prevention equipmentwas inspected in accordance v�t1�� o�1,�tof,`k2egulatiPt��riTitle 23, Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accura e. 1-1 A '.�r, _ UST Service Technician Signature _ 6f ��e 4L If the facility has more components than this form accommodates, additional copies of this page may be attached. 'ERS = California Environmental Reporting System, ID = Identfication, UST =Underground Storage Tank, ICC = International Code Council, AN= Audible and Usual