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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) FTy=peofon ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10120456 8/15/19 Business Name (Same as Facility Name or DBA-Doing Business As) Rancho San Miguel Market Business Site Address City ZIP Code 1427 S . Airport Way Stockton 95206 ll . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Steve White 1 (408) 971 -2445 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 485184 8898679 5/ 10/20 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) 1016243710 / C24135 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ® Manufacturer Guidelines (Specify) : OPW Used : ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) T2 91 What is the tank inside diameter? (Inches) 112 Is the fill piping secondarily contained? ❑ Yes ❑ No 171 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW 61 -SO What is the overfill prevention equipment response ❑ Shuts Off Flow Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? ❑ (Check all that apply.) Restricts Flow ❑ Restricts Flow C] Restricts Flow El Restricts Flow ❑ AAV Alarm ® A/V Alarm ❑ A/V Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? ❑ Yes ❑ No © Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 98 . 75 What is the percent capacity of the tank at which the overfill prevention equipment activates? 93 . 3% Is the overfill prevention in proper operating condition ❑ Yes ® Yes ❑ Yes ❑ Yes i to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V) ❑ No (Specify in V) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. Have to return to remove 87 drop tube VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with Califo r�i ( oc� q# iRegtllatloos , Title 231 Division 3, Chapter 16 , Section 2637 .2 and all the information contained herein is dcti -) $` I $;mt UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Usual ll