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7/9/2021 647555353 .jpg UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) ; i, IIIIIType of Action T _ ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Unla of Overfill PfevenNon Equipment Inspection 101805G7 8/23/ 1 Business Name (Same as Facility Alamo or DBA-Doing Business As) - - EMILS LIQUOR Business Site Address City ZIP Code 1405 CALIFORNIA ST _ _ ESCALON 95320 il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as sho:vn on the ICC Certification) Phone # Edward Stearns (209) 744 -0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Dare 14 - 1760 Ex . 09/30/2020 8883080-UT 11 /912020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable codifications.) i FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11 /29/2020 OPW 104-635 Ex 3-14-2020 r. Emco 3205 Ex. 11 / 16/2020 ATG : VR A31048 Ex.8/9/19 Incon 1009893708 11 /30/2_020 lilt OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspedion Melhod 21 Manufacturer Guidelines (Specih): Used: REMOVE AND INSPECT OPW i ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Affached Pages 2 i TANK ID: (By tank number, stored product, etc) DIESEL Mat is the tank inside diameter? (inches) 128 is the fill piping secondarily contained? ❑ Yes Q No ❑ Yes ❑ No ❑ 'res ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes R) No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturers) _ OPW_ 71S0 'mat is the overfill prevention equipment response ❑x Shuts Oft Flow ❑ Shhds Off Flow ❑ Shuts Off F(o• v ❑ Shuts Off Flow tI when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flocr (Check all that apply,) j DAN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restdctors if, on vent piping? ❑ Yes d No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ' At what level in the lank is the overfill prevention set 115 to activate? (Inches from bottom of tank ) 3 What is the percent capacity of the tank at which the 94 * 8 overfill prevention equipment aaivates ? Is the overfill ptoventionin proper opoialing condition t] Yes ❑ Yes ❑ Yes ❑ Yes f i to respond when the substance leeches the appropriate level? ❑ No (Specify in V) ❑ No (Spa ciyin V.) ❑ No (Specify In V.) ❑ No (SpecilyIn V.) Y ; We SUMMARY OF INSPECTION RESULTS r `' Overfill Prevention Inspection Resrdts Ex1 Pass El Fall Li Pass U. [] Prix ❑ Fal ❑ Pass Q Fall W11 V. COMMENTS Any darns marked 'Fail" must be explaiaad in this section. Any additional comments bray also be provided here. .: l VI. CERTIFICATION BY UST 'SERVICE TECHNICIAN CONDUCTING THIS INSPECTION _ I hereby certify thatthe ovorf lit prevention equipment was inspected In accordancowilh California Code of Roguladons , Title 23, Division 3, Chapter 16, Socfion 2637.2 and all the Information coAtainod heroin is accurate. ' — UST Service Technician signature If ftia radfity has morn components than this ronn acconmrodatest additional eoptes of thio pajo rnnyba attached. CURS = CW0TVa UnWar'mcnu Repoil�hg Syafent ID = Iden 6catat UST ' Dnda6`ixxxt SiaaW Ta* ICC In �Ynito aI Code Council. M! = P die and Vo sdLq It 14 44 'milt I't c littps ://niail .google.com/niail/u/O/? tab= km#inbox?projector= 1 1 / 1