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MENNEN- <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 Date of Overfill Prevention Equipment Inspection <br /> 11 / 15/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Flyers #427 <br /> Business Site Address City ZIP Code <br /> 3300 Waterloo Rd Stockton 95205 <br /> 118 UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Nicholas Janoe ( 916 ) 373 - 1166 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8712764 4/ 11 /2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> OPW <br /> y 3 <br /> 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION fNFATtt:) N <br /> Inspection Method 9 Manufacturer Guidelines (Specify) : Y � <br /> c ; <br /> Used : OPW Install & Maintenance Guidelines 11 . <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> r, <br /> ❑ Engineered Method (Specify) : <br /> F)E ��'� i�� � ��� �� <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) 87 Gasoline Diesel <br /> What is the tank inside diameter? (Inches) 95 95�� <br /> Is the fill piping secondarily contained ? ❑ Yes [j] No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? ❑x Restricts Flow 9 Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) <br /> ❑ AIV Alarm ❑ AA/ Alarm ❑ AfV Alarm ❑ AIV Alarm <br /> t <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> s At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 86 86 <br /> What is the percent capacity of the tank at which the o 0 <br /> overfill prevention equipment activates? 95 % 95 /o <br /> I Is the overfill prevention in proper operating conditionZ Yes ❑Q Yes El Yes El Yes <br />' to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Pass El Fail 9Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass El Fail <br /> V. COMMENTS <br /> Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23 , <br /> Division 3 , Chapter 16 , Section 2637.2 and all the information contained herein is accurate . <br /> UST Service Technician Signature ' /l / <br /> NGS <br /> If the facility has more components than this form a66ommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Visual <br />�i <br /> i <br />