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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection I . 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 Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Steve White k 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 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No i 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 E:]] Shuts Off Flow Shuts Off Flow ❑ Shuts Off Flow El Shuts Off Flow when activated ? (Check all that apply.) E] Restricts Flow ElRestricts Flow ElRestricts Flow ElRestricts Flow ❑ AN Alarm ® AN Alarm ❑ AN Alarm ❑ AN 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 E overfill prevention equipment activates? 93 . 3% Is the overfill prevention in proper operating condition ❑ Yes ® Yes ❑ Yes ❑ Yes 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 "Faitmust be explained in this section. Any additional comments may a Have to return to remove 87 drop tube n L . ? VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with JVAV 1i tUN it! eVuliitr-r� i6 23 , Division 3, Chapter 16, Section 2637. 2 and all the information contained herein is accurate. F) F PA Vt UST Service Technician Signature l J If the facility has more components than this form accommodates, additional copies of this page may be attached. cCERS = Calffomia Environmental Reporting System, ID = Idendcation, UST = Underground Storage Tank, ICC = IMemational Code Council, AN = Audible and Visual