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� t7D Om m v OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of 1) t; O C/) Type of Action O N N N El installation Inspection 01 CD ❑Repair Inspection ®36 Month Inspection N N c� CERS ID !.FACILITY INFORMATION �_ oN CDC 10166181 Dale of Overfill Prevention Equipment Inspection `O N G nl Business Name(Same as Facility Name or DBA-Doing Business As.) 05/30/19 Q = s Hammer i-5 c v � Arco ° � Business Site Address 3201City ZIP Code W. Hammer Lane (D Stockton 95209 r Name of UST QJ !I. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Service Technician Pe rorming the Inspection(Print as shown on the ICC Certification.) Phone# Isaac Anderson CD Contractor Tank Tester License# 209 532-7320 Ext. Cf) Certification# ICC Certification Expiration Date Tank 7 �- ester 09-1749 8146912 06/12/24 ° 0 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) n P 4 1 2 Cn o Inspection Method Used: Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION ..0 ®Manufacturer Guidelines(specify)measure from tank bottom to mechanical floatirecord height. ❑industry Code or Engineering Standard(Specify) (p ❑Engineered Method(Specify) rr Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages: � Tank IID:(By tank number,stored product,etc.) T1 87 Master T2 87 Syphon T3 91 `(D What is the tank inside diameter?(inches) 92 n 92 92 Is the fill piping secondarily contained? ° ®Yes ❑No ®Yes ❑No ®Yes ❑No E]Yes ❑No � Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ®No ❑Yes ®No ❑Yes ❑No CD OPW OPW OPV Overfill Prevention Equipment Manufacturer(s) ° What is the overfill prevention equipment ®Shuts Off Flaw ®Shuts Off Flow ®Shuts Off Flow ❑Shuts Off Flow response when activated? ❑Restricts Flaw ❑Restricts Flow ❑RLstncts Flow ❑Restricts Flow SD- (Check all that apply.) ❑AIV Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ❑Yes ®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.) 82 82 81 What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 L 94 93 is the overfill prevention in proper operating ®Yes ®Yes ®Yes ❑Yes condition to respond when the substance ❑No ❑No ❑No reaches the appropriate level? (Specify in section V.) (Specify . ❑No in section V) (Specify in section V.) (Specify in section V.) 1V, SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ®Pass 0 Fail ®Pass ❑Fail ®Pass ❑Fail ❑Pass ❑Fall V. COMMENTS All items marked"Fail"must be explained in this section. Any additional comments may also be provided here. O (D n � O v Q C cn VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION o LUS:TS:ervjc0 ereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,title 23,division 3, w apter 16,section 2637.2 and alt the information c tained herein is accurate. N rD N N Technician Signature 0 N Nthe facility has more component an this form accommodates,additional copies of this page may be attached. rv=at;x r xwnmia Gr,,,irnnmonlal P-n rfinn Rucfpm In=Wonfi5rafdnn I IRT=I Inriamml Ind cfnrana fano If r'=Intomalinrul r.rrin r L^,rnril on1=fi-lir,la and