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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 Z 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 1 / 16/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> California Stop <br /> Business Site Address City ZIP Code <br /> 2224 S Manthey Rd TStockton 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 /> Brian Dunahay (248) 978- 5420 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 956593 8021436-UT 12/16/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) t n tl <br /> Overfill Cert : PEIRP1200 10/9/2018 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION , <br /> Inspection Method ❑ Manufacturer Guidelines (Specify) : <br /> Used : <br /> ❑x Industry Code or Engineering Standard (Specify) : THI <br /> RP1200 E Vi i <br /> f\A <br /> j ❑ Engineered Method (Specify): - 1 l3) ' <br /> i <br /> Attach the inspection procedures and all documrtration required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) 87 Diesel <br /> What is the tank inside diameter? (Inches) 92 92 <br /> Is the fill piping secondarily contained ? ❑ Yes x❑ No ❑ Yes El No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes Q No ❑ Yes N No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow Q Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply) ElRestricts Flow ElRestricts Flow ElRestricts Flow ElRestricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention at <br /> to activate? (Inches from bottom of tank.) 82 82 <br /> What is the percent capacity of the tank at which tilt <br /> overfill prevention equipment activates? 95 95 <br /> Is the overfill prevention in proper operating condition 0 Yes 0 Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? L, No (Sperisy in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ElFail 9 Pass ED] Fail' F ❑ Pass E] Fail E] Pass El 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 equipmentwas 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 /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual <br />