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�'( r1 ti 047 <br /> s / <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page t of 1) <br /> Type of Action E Installation Inspection ❑Repair inspection ❑36 Mm'tth Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Insoemaai <br /> 5/1/2020 <br /> Business Name(Sarre as Facility Name or DBA-Doing Business As) <br /> Alpha Fast Gas <br /> Business Site Address Gih 7 P Code <br /> 2358 Waterloo Rd Stockton 9520d <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the inspection(Print as shown on the ICC CertifcaLon.) Phone# <br /> Chris Adams (209)461-63-- <br /> Contractor I Tank Tester License# ICC CertificationDate <br /> #13230218 ICC 6 1 cationgallon <br /> 1001331 A-HAZ —_ <br /> Overfill Prevention Equipment Inspection Training and Certifications(Lisi applicable certifications.) <br /> OPW 100305 Exp 512312021 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Manufacturer Guidelines jSpaorfy) <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify)' <br /> ❑Engineered Method(Specify): <br /> #of Attadieo PagE- <br /> Attach the inspection procedures and all documentation required to determine the results. <br /> -- <br /> TANK In:(By tank number,stored product,etc) 87 <br /> VVhal is the tank inside diameter?(inches) 96" <br /> Is the fill piping secondarily contained? Q Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes r <br /> is the vent piping secondarily contained? El Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes uo <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What Is the overfill prevention equipment response ❑x Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off F l— <br /> when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Res,,-. <br /> (Check all that apply) <br /> ❑AN Alarm ©AN Alarm ❑AIV Alarm ❑Arti�_Are flow restrictors installed on vent piping? ❑Yes E No ❑Yes ❑No ❑Yes ©No Cl Yes _ .. <br /> At what level in the tank is the overfill prevention set <br /> to activate?(inches from bottom of tank) <br /> What is the percent capacity of the tank at which the 93% <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operati=es , <br /> es El Yes ©Yes ❑Yes <br /> to respond when the substance re –•---- <br /> appropnate level? o(Specify in V.) ❑No(Specify in V) ❑No(Specify in V) ❑No r,Soc <br /> IV. SUMMARY OF INSPECTION RESULTS _ <br /> Overfill Prevention Inspection Results Pass ❑Fail 1 ( Pass ❑Fad 1 ❑Pass ❑Fail ❑Pass <br /> V. COMMENTS <br /> Any items marked'Fail"must be explained in this section. Any additional comments may also be provided here. <br /> FVL CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> h.riby rtify that theoverfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, <br /> Chapter 16,Section 2637.2 and ail the Information contained herein Is accurate. <br /> UST Service Technician Signature /) Azle t <br /> if the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Caifoma Environmental Reporting System,U)=ider-dcAm UST=lblderground Storage Tank r-C=#rdernatiOnai Code Card.AIV=Awls and V&A <br />