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Type of Action CERS ID UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 9 of fl ❑ Installation Inspection Repair Inspection ❑ 36 Month Inspection I. FACILITY INFORMATION Date of Overfill Prevention Equipment Inspection 1/16/2019 Business Name (Same as Facifity Name or DBA -Doing Business As) Escalon Mini Mart Business Site Address City 1097 E. Yosemite Ave.. Escalon II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service 1 hniclan Performing the Inspection (Print as shown on the !CC certification.) Phoner209� 537-9396 Miguel Zaragoza ll Contractor 1 Tank Tester Li Certificaiton Expiration Date 8/4/2099 Overfill Prevention Equit OPW #175405 Inspection Method Used: License 95320 # ICC Certification # ICC 8296444 nt Inspection Training and Certifications (List applicable certifications.) Franklin Fueling #2996953702 Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION ❑x Manufacturer Guidelines (Specify): ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Afiarh the inspection procedures and all documentation required to determine the results. I # of TANK ID: fBy tank number, stored product, etc.) 91 What is the tank inside diameter? (inches) 1 11 Is the fill piping secondarily contained? ❑ Yesx❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes El No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Phil Tite - Franklin Defender Series What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow EJ Shuts Off Flow when activated? ❑x Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑Restricts Flow (Check all that apply.) ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrkctors installed on vent piping? ❑ Yes l] No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set 100 1/8 to activate? finches from bottom of tank.) What is the percent capacity of the tank at which the o 95 �o overfill prevention equipment activates? Is the overfill prevention in proper operating condition ElYes D Yes ❑ Yes ❑ Yes to respond when the substance reaches the ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V} ❑ No fSpecify in V.} annrooriate levet? Overfill Prevention IV. SUMMARY OF INSPECTION RESULTS Results Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS items marked "Fall" 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 that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2637.2 an all the information contained herein is accurate. UST Service Technician Signature fp LOP I If the facilifyhas more components fhan this form ac—coV oda s, a ditional copies of this page maybe attached. CERS = Catfornia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AIV = Audible and Visual