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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 1. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10120456 10/08/19 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 # Steven White 14089712445 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 485184 1 8898679 05/10/20 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) 1016243710 / C24135 III . 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.) T1 -87 What is the tank inside diameter? (Inches) 119 Is the fill piping secondarily contained? ❑✓ Yes ❑ No ❑ 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 71 -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.) ElRestricts Flow ❑ Restricts Flow ElRestricts Flow C1Restricts Flow ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping? FLI 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? 91 . 8 % Is the overfill prevention in proper operating condition ® Yes ❑ Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level? [I No (Specify in V.) El No (Specify in V.) El No (Specify in V.) El 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. IV r X��g R E T VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTINIWTI lg WWRCTION I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations, Title 230 Division 3, Chapter 16, Section 2637 . 2 and all the information contained herein s accurate. UST Service Technician Signature '- t r If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Caffomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = intemationai Code Council, AN = Audible and Visual