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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180819 12- 11 -2018 i Btainess Name (Same as Facility Name or DBA-Doing Business As) MY MINI MART Business Site Address City ZIP Code 1756 N W(SON WAY STOCKTON 95205 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on tfe ICC Certification.) Phone # David Winkler 1 (209 ) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 0 & 1739 Ex . 3/31 /2020 8883059-LJT 1 /29/2020 Overfill Prevention Equipment Ins ae :x� Training and Certifications (List a^ � z FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11 -29-20 O ii"rr 1 3 & r14-2020 Emco #3207 Ex. 09-21 -2020 VR : B34975 ATG: 2/820 HL OVERFILL PREVENTION EQUIPMENT INSPECTION INF91tMATION , Inspection Method Z tan- � ,rer Guidelines (Specify): REMOVED OPW DROP TUBES Used : d- ;Vry Code or Engineering Standard (Specify) : Erxeered Method (Specify) : I Attach the inspection procedures and all documentation required to determine the r sults. 4TfAttac d Pages TANK ID : (By tank number, st°vedp= oduct, etc.) 87 91 What is the tank inside diameter? ( s) 92 92 w *'J Is the fill piping secondarily contained? ❑ Y 7 tic 1 Yes E No ❑ ❑ Yes [INo Is the vent piping secondarily contained? ❑ Yes No ❑ Yes 0 No ❑ Yes ❑ No El Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPOW opwali 61SO E S What is the overfill prevention equipment response Q Shuts Off Flow L Sx zs Off Fes, ❑ SFuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) ❑ Restricts Flow ❑ ❑ Restricts Flow ❑ Restricts Flow ❑ AN Alarm a; Alv Aim ❑ A/V Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑ Yes Z No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 823/4 83 What is the percent capacity of the tank at which the overfill prevention equiprnent activates? 94 95 Is the overfill prevention in proper gating condition ❑x Yes Z Yes ❑ Yes ❑ Yes to respond when the sutxstarce 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 Rem. s Z Pass ❑ Fal Z Pass (:--]:F ail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. J&N O &PNIA, 62021 I VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INS11 M I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regular Wi 23 , Division 3 , Chapter 16, Section 2637 .2 and all the information contained herein is accurate . fr UST Service Technician Signature �. If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Caklbrnia Environmental Reporting Systern, ID = kieracation, UST = Underground Storage Tank, ICC = Intematianal Code Coundl, AA/ = Audible and Visual