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UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑Installation Inspection [I Repair Inspection 36 Month Inspection <br />1. FACILITY INFORMATION <br />Date of Overfill Prevention Equipment Inspection <br />_ERS ID 10180637 2/21/2019 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />GEMCO RIPON TRUCK PLAZA ZIP code <br />Business Site Address City <br />1022 S. FRONTAGE ROAD RIPON 95366 <br />STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />II, UNDERGROUND <br />Phone # <br />Name of UST Service Technician Performing the Inspection (print as shown on the ICC Certification.) (209) 744-0112 <br />Zane Nimmo ICC Cert (ration Expiration Date <br />Contractor / Tank Tester License # ICC Certification # 611/2019 <br />04-1676 Ex.03/31/2019 8883064 -UT <br />Overfill Prevention Equipment Inspection Training and certifications (List applicable certifications.) <br />FF- EBW , Phil-Tite Sr EVR Phase 1 10009843708 Ex 11-29-20 OPW 104-632 Ex 3-14-2020 <br />Incon # 1009843708 Ex.11-30-20 <br />Emco 3206 Ex. 11/1412020 ATG: VR: A28446 Ex. 9/28/19 <br />EQUIPMENT INSPECTION INFORMATION <br />OVERFILL PREVENTION <br />urer Guidelines (Specify): O P W PHASE I TESTING <br />tTE01 <br />Code or Engineering Standard (Specify): <br />ed Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages <br />4 <br />TANK ID: (By tank number, stored product, etc.) <br />1 - 87 OCT <br />2 - 91 OCT <br />What is the tank inside diameter? (Inches) <br />113.75 <br />113.75 <br />the fill piping secondarily contained? <br />❑ Yes ©No <br />❑ Yes 0 No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes ®No <br />❑ Yes 0 No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW <br />OPW <br />What is the overfill prevention equipment response <br />0 Shuts Off Flow <br />0 Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />when activated?❑ <br />Restricts Flow <br />[IRestricts Flow <br />❑ Restricts Flow <br />❑ Restricts Flow <br />(Check all that apply.) <br />❑ AN Alarm <br />❑ AN Alarm <br />❑ AN Alarm <br />❑ A/V Alarm <br />Are flow restnctors installed on vent piping? <br />❑ Yes ® No <br />❑ Yes 0 No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />9$ Q" <br />99.0 <br />to activate? (Inches from bottom of tank.) <br />What Is the percent capacity of the tank at Which the <br />91 % <br />92% <br />overfill prevention equipment activates? <br />Is the overfill prevention in proper operating condition 0 Yes 0 Yes ❑ Yes ❑ Yes <br />to respond when the substance reaches the <br />[I No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br />appropriate level? <br />IV. SUMMARY OF INSPECTION RESULTS <br />Overfill Prevention Inspection Results 0 Pass ❑ Fail 0 Pass ❑ Fail ❑Pass ❑Fail ❑Pass ❑Fail <br />V. COMMENTS <br />Any 'ems marked "Fail" must be explained in this section. Any additional common fs may also be provided here. <br />CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />VI. <br />_ r_r.:_...:.. r. _ of Gnnnhtinns. Title 23. <br />tereby certify that the overfill prevention equipment was inspecitoo 1" duWival I. <br />Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />ff the facility has more components than this form accommodates, additional copies of this page may be attached <br />CERS = Califomla Environmental Repo" System, ID = k%nt katim. UST = Underground Storage Tank, ICC = Intemaboral Code Council, AN = Audible and Visual <br />