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s � UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page t of"1) Type of Action Installation Inspection ❑Repair Inspection ❑36 Month Inspection I. FA61LITY:INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 5/1/2020 Business Name(Same as Facility Name or DBA-Doing Business As) Alpha Fast Gas Business Site Address City ZIP Code 2358 Waterloo Rd Stockton 95205 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION . ...... ........... .... Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Chris Adams (209) 461-6337 Contractor i Tank Tester License# ICC Certification# ICC Certification Expiration Date 8230218 1001331 A-HAZ 6/19/2021 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) OPW 109305 Exp 5/23/2021 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION'_ Inspection Method Manufacturer Guidelines(Specify): 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.) 87 What is the tank inside diameter?(inches) 96" Is the fill piping secondarily contained? Z Yes ❑ No ❑Yes ❑No ❑Yes ❑No ID Yes ❑No Is the vent piping secondarily contained? Z Yes ❑ No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment response ❑x Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activated? ❑ Restricts Flow ❑Restricts Flow El Restricts Flow ❑ Restricts Flow (Check aIl that apply.) ❑A1V Alarm ❑AIV Alarm ❑AIV Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ❑Yes Z 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.) What is the percent capacity of the tank at which the overfill prevention equipment activates? 93% Is the overfill prevention in proper operating condition ❑x Yes es ❑Yes El Yes to respond when the substance reaches the appropriate level? ❑No(Specify in V. ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V) I.Y. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass ❑Fail ❑ Pass ❑ Fail ❑Pass ❑f=ail 11 ❑ Pass ❑ Fail V. COMMENTS Any items marked Fail"must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING'THIS INSPECTION. I hereby certify thatthe overfill prevention equipmentwas inspected in accordance with California Code of Regulations,Title 23, Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=Carifomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual