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If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council, <br />UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection n 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Overfill Prevention Equipment Inspection <br />10413073 <br />3/27/19 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />COUNTRY MARKETPLACE <br />Business Site Address City <br />ZIP Code <br />1789 W. CHARTER WAY STOCKTON <br />95203 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) <br />Phone # <br />Edward Stearns <br />(209) 744-0112 <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />14-1760 Ex. 09/30/2020 <br />8883080 -UT <br />11/9/2020 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />FF- EBW PhikTite & EVR Phase 1 1009893708 Ex 11/29/2020 OPW 104-635 Ex 3-14-2020 <br />, <br />Emco 3205 Ex. 11/16/2020 ATG: VR A31048 Ex.8/9/19 Incon 1009893708 11/30/2020 <br />Ili. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />❑x Manufacturer Guidelines (Specify): <br />Used: <br />90% VR <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages 4 <br />TANK ID: (By tank number, stored product, etc.) <br />1-87 <br />2-91 <br />What is the tank inside diameter? (Inches) <br />128.06 <br />96 <br />Is the fill piping secondarily contained? <br />❑ Yes El No <br />❑ Yes ❑x No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes ❑x No <br />❑ Yes ❑x No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />VEEDER ROOT <br />VR <br />What is the overfill prevention equipment response <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />when activated? <br />❑Restricts Flow <br />El Restricts Flow <br />❑Restricts Flow <br />❑Restricts Flow <br />(Check all that apply.) <br />❑x A/V Alarm <br />❑x A/V Alarm <br />❑ AIV Alarm <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />x❑ Yes ❑ No <br />0 Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />107,87 <br />80.87 <br />What is the percent capacity of the tank at which the <br />90 <br />90 <br />overfill prevention equipment activates? <br />Is the overfill prevention in proper operating condition <br />❑x Yes <br />Z Yes <br />❑ Yes <br />❑ Yes <br />to respond when the substance reaches the <br />appropriate level? <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />ElNo (Specify in V) <br />ElNo (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />9 Pass ❑Fail <br />❑x Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑Pass ❑ Fail <br />V. COMMENTS <br />Any items marked "Fail' must be explained in this section. Any additional comments -ayjIso`be proyided here. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />hereby certify that the overfill prevention equipment was inspected in accordanc iGda"f.k 6 Title 23, <br />Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accuratp�tF� I ) v A <br />UST Service Technician Signature <br />I `_, <br />AN =Audible and Usual <br />