Appendix IX Underground Storage Tank

Overfill Prevention Equipment Inspection Report Form

CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, OPE = Overfill Prevention Equipment

TYPE OF ACTION Installation Repair 36 Month

1. FACILITY INFORMATION

CERS ID Inspection Date

Facility Name

Facility Address City ZIP Code

2. SERVICE TECHNICIAN INFORMATION

Company Performing the Phone

Mailing Address

Service Technician Performing Inspection

Contractor/Tank Tester License Number

ICC Number Expiration Date

3. TRAINING AND CERTIFICATIONS

Manufacturer and Test Equipment Training Certifications Expiration Date

4. INSPECTION PROCEDURES INFORMATION

Inspection Procedures Used Components Inspected

5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION

I hereby certify that the OPE was inspected in accordance with California Code of

Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting documentation is attached; and all information contained herein is accurate. I understand that test procedures shall be made available upon request by the governing authority.

Service Technician Signature Date Total # of Pages

10040881 05/20/2024

JERRY PETTIS MEMORIAL VETERANS HOSPITAL

11201 BENTON STREET, LOMA LINDA, CA 92357

WESTERN PUMP INC. (619) 239-9988

3235 F STREET, SAN DIEGO, CALIFORNIA 92102

RAUL GONZALEZ

673853

8374555 11/14/2025

OPW - 116874 02/02/2026

PEI | RP1200 - AUTOMATIC SHUT OFF DEVICE T1: DIESEL, T2: AMBER 363, T3: AMBER

05/20/2024 7

Underground Storage Tank Overfill Prevention Equipment Inspection Report

Additional copies of this page may be attached.

Attach tank chart(s), measurements, calculations, and In-Tank Setup report(s)

6. OVERFILL PREVENTION EQUIPMENT DETAILS

Tank ID (one OPE per column)

Are both vent and tank riser piping secondarily contained?

Yes

No

Yes

No

Yes

No

Yes

No

OPE Model

What is the OPE response when activated?

(Check all that apply.)

Shut off

Flow

Restricts

Flow

Audible

Alarm

Visual

Alarm

Shut off

Flow

Restricts

Flow

Audible

Alarm

Visual

Alarm

Shut off

Flow

Restricts

Flow

Audible

Alarm

Visual

Alarm

Shut off

Flow

Restricts

Flow

Audible

Alarm

Visual

Alarm

Are flow restrictors installed on vent piping that may interfere with the OPE operation?

Yes

No

Yes

No

Yes

No

Yes

No

At what level in the tank is the OPE set to activate? (Inches from bottom of tank)

What is the percent capacity of the tank at which the OPE activates?

Is the OPE in proper operating condition to respond when the stored substance reaches the designated regulatory level?

Yes

No

Yes

No

Yes

No

Yes

No

7. SUMMARY OF TESTING RESULTS

OPE Inspection Results Pass

Fail

Pass

Fail

Pass

Fail

Pass

Fail

8. COMMENTS

Describe all results marked “Fail” and each proposed remedy.

* Mark here if:

Flow restrictors interfere with overfill prevention and equipment repairs required.

-T1-

71SO 71SO 71SO

104.50 105.25 105.25

94.43 94.91 94.91

-T2- -T3-

8-5/8"

8-3/4"

8-7/8"

9"

9-1/8"

9-1/4"

9-3/8"

9-1/2"

9-5/8"

9-3/4"

9-7/8"

10"

10-1/8"

10-1/4"

10-3/8"

10-1/2"

10-5/8"

10-3/4"

10-7/8"

11"

11-1/8"

11-1/4"

11-3/8"

11-1/2"

11-5/8"

11-3/4"

11-7/8"

12"

12-1/8"

12-1/4"

12-3/8"

12-1/2"

12-5/8"

12-3/4"

12-7/8"

13"

13-1/8"

13-1/4"

13-3/8"

13-1/2"

13-5/8"

13-3/4"

13-7/8"

14"

14-1/8"

14-1/4"

14-3/8"

14-1/2"

14-5/8"

14-3/4"

14-7/8"

15"

15-1/8"

15-1/4"

15-3/8"

15-1/2"

15-5/8"

15-3/4"

15-7/8"

16"

16-1/8"

16-1/4"

16-3/8"

16-1/2"

16-5/8"

16-3/4"

16-7/8"

17"

25-5/8"

25-3/4"

25-7/8"

26"

26-1/8"

26-1/4"

26-3/8"

26-1/2"

26-5/8"

26-3/4"

26-7/8"

27"

27-1/8"

27-1/4"

27-3/8"

27-1/2"

27-5/8"

27-3/4"

27-7/8"

28"

28-1/8"

28-1/4"

28-3/8"

28-1/2"

28-5/8"

28-3/4"

28-7/8"

29"

29-1/8"

29-1/4"

29-3/8"

29-1/2"

29-5/8"

29-3/4"

29-7/8"

30"

30-1/8"

30-1/4"

30-3/8"

30-1/2"

30-5/8"

30-3/4"

30-7/8"

31"

31-1/8"

31-1/4"

31-3/8"

31-1/2"

31-5/8"

31-3/4"

31-7/8"

32"

32-1/8"

32-1/4"

32-3/8"

32-1/2"

32-5/8"

32-3/4"

32-7/8"

33"

33-1/8"

33-1/4"

33-3/8"

33-1/2"

33-5/8"

33-3/4"

33-7/8"

34"

34-1/8"

34-1/4"

34-3/8"

34-1/2"

34-5/8"

34-3/4"

34-7/8"

35"

35-1/8"

35-1/4"

35-3/8"

35-1/2"

35-5/8"

35-3/4"

35-7/8"

36"

36-1/8"

36-1/4"

36-3/8"

36-1/2"

36-5/8"

36-3/4"

36-7/8"

37"

37-1/8"

37-1/4"

37-3/8"

37-1/2"

37-5/8"

37-3/4"

37-7/8"

38"

38-1/8"

38-1/4"

38-3/8"

38-1/2"

38-5/8"

38-3/4"

38-7/8"

39"

39-1/8"

39-1/4"

39-3/8"

39-1/2"

39-5/8"

39-3/4"

39-7/8"

40"

40-1/8"

40-1/4"

40-3/8"

40-1/2"

40-5/8"

40-3/4"

40-7/8"

41"

41-1/8"

41-1/4"

41-3/8"

41-1/2"

41-5/8"

41-3/4"

41-7/8"

42"

42-1/8"

42-1/4"

42-3/8"

42-1/2"

42-5/8"

42-3/4"

42-7/8"

43"

43-1/8"

43-1/4"

43-3/8"

43-1/2"

43-5/8"

43-3/4"

43-7/8"

44"

44-1/8"

44-1/4"

44-3/8"

44-1/2"

44-5/8"

44-3/4"

44-7/8"

45"

45-1/8"

45-1/4"

45-3/8"

45-1/2"

45-5/8"

45-3/4"

45-7/8"

46"

46-1/8"

46-1/4"

46-3/8"

46-1/2"

46-5/8"

46-3/4"

46-7/8"

47"

47-1/8"

47-1/4"

47-3/8"

47-1/2"

47-5/8"

47-3/4"

47-7/8"

48"

48-1/8"

48-1/4"

48-3/8"

48-1/2"

48-5/8"

48-3/4"

48-7/8"

49"

49-1/8"

49-1/4"

49-3/8"

49-1/2"

49-5/8"

49-3/4"

49-7/8"

50"

50-1/8"

50-1/4"

50-3/8"

50-1/2"

50-5/8"

50-3/4"

50-7/8"

51"

51-1/8"

51-1/4"

51-3/8"

51-1/2"

51-5/8"

51-3/4"

51-7/8"

52"

52-1/8"

52-1/4"

52-3/8"

52-1/2"

52-5/8"

52-3/4"

52-7/8"

53"

53-1/8"

53-1/4"

53-3/8"

53-1/2"

53-5/8"

53-3/4"

53-7/8"

54"

54-1/8"

54-1/4"

54-3/8"

54-1/2"

54-5/8"

54-3/4"

54-7/8"

55"

55-1/8"

55-1/4"

55-3/8"

55-1/2"

55-5/8"

55-3/4"

55-7/8"

56"

56-1/8"

56-1/4"

56-3/8"

56-1/2"

56-5/8"

56-3/4"

56-7/8"

57"

57-1/8"

57-1/4"

57-3/8"

57-1/2"

57-5/8"

57-3/4"

57-7/8"

58"

58-1/8"

58-1/4"

58-3/8"

58-1/2"

58-5/8"

58-3/4"

58-7/8"

59"

59-1/8"

59-1/4"

59-3/8"

59-1/2"

0-1/8"

0-1/4"

0-3/8"

0-1/2"

0-5/8"

0-3/4"

0-7/8"

1"

1-1/8"

1-1/4"

1-3/8"

1-1/2"

1-5/8"

1-3/4"

1-7/8"

2"

2-1/8"

2-1/4"

2-3/8"

2-1/2"

2-5/8"

2-3/4"

2-7/8"

3"

3-1/8"

3-1/4"

3-3/8"

3-1/2"

3-5/8"

3-3/4"

3-7/8"

4"

4-1/8"

4-1/4"

4-3/8"

4-1/2"

4-5/8"

4-3/4"

4-7/8"

5"

5-1/8"

5-1/4"

5-3/8"

5-1/2"

5-5/8"

5-3/4"

5-7/8"

6"

6-1/8"

6-1/4"

6-3/8"

6-1/2"

6-5/8"

6-3/4"

6-7/8"

7"

7-1/8"

7-1/4"

7-3/8"

7-1/2"

7-5/8"

7-3/4"

7-7/8"

8"

8-1/8"

8-1/4"

8-3/8"

8-1/2"

17-1/8"

17-1/4"

17-3/8"

17-1/2"

17-5/8"

17-3/4"

17-7/8"

18"

18-1/8"

18-1/4"

18-3/8"

18-1/2"

18-5/8"

18-3/4"

18-7/8"

19"

19-1/8"

19-1/4"

19-3/8"

19-1/2"

19-5/8"

19-3/4"

19-7/8"

20"

20-1/8"

20-1/4"

20-3/8"

20-1/2"

20-5/8"

20-3/4"

20-7/8"

21"

21-1/8"

21-1/4"

21-3/8"

21-1/2"

21-5/8"

21-3/4"

21-7/8"

22"

22-1/8"

22-1/4"

22-3/8"

22-1/2"

22-5/8"

22-3/4"

22-7/8"

23"

23-1/8"

23-1/4"

23-3/8"

23-1/2"

23-5/8"

23-3/4"

23-7/8"

24"

24-1/8"

24-1/4"

24-3/8"

24-1/2"

24-5/8"

24-3/4"

24-7/8"

25"

25-1/8"

25-1/4"

25-3/8"

25-1/2"

Dipstick Calibration Chart for 20,000 Gallon - 10' Diameter DWT-II Tank

7O89

10015

10043

10070

10097

XERXES CORPORATION Dipstick Calibration Chart for 20,000 Gallon - 10' Diameter DWT-II Tank

59-5/8"

59-3/4"

59-7/8"

60"

60-1/8"

60-1/4"

60-3/8"

60-1/2"

60-5/8"

60-3/4"

60-7/8"

61"

61-1/8"

61-1/4"

61-3/8"

61-1/2"

61-5/8"

61-3/4"

61-7/8"

62"

62-1/8"

62-1/4"

62-3/8"

62-1/2"

62-5/8"

62-3/4"

62-7/8"

63"

63-1/8"

63-1/4"

63-3/8"

63-1/2"

63-5/8"

63-3/4"

63-7/8"

64"

64-1/8"

64-1/4"

64-3/8"

64-1/2"

64-5/8"

64-3/4"

64-7/8"

65"

65-1/8"

65-1/4"

65-3/8"

65-1/2"

65-5/8"

65-3/4"

65-7/8"

66"

66-1/8"

66-1/4"

66-3/8"

66-1/2"

66-5/8"

66-3/4"

66-7/8"

67"

67-1/8"

67-1/4"

67-3/8"

67-1/2"

67-5/8"

67-3/4"

67-7/8"

68"

68-1/8"

68-1/4"

68-3/8"

68-1/2"

68-5/8"

68-3/4"

68-7/8"

69"

69-1/8"

69-1/4"

69-3/8"

69-1/2"

69-5/8

69-3/4"

69-7/8"

70"

70-1/8"

70-1/4"

70-3/8"

70-1/2"

70-5/8"

70-3/4"

70-7/8"

71"

71-1/8"

71-1/4"

71-3/8"

71-1/2"

71-5/8"

71-3/4"

71-7/8"

72"

72-1/8"

72-1/4"

72-3/8"

72-1/2"

72-5/8"

72-3/4"

72-7/8"

73"

73-1/8"

73-1/4"

73-3/8"

73-1/2"

73-5/8"

73-3/4"

73-7/8"

74"

74-1/8"

74-1/4"

74-3/8"

74-1/2"

74-5/8"

74-3/4"

74-7/8"

75"

75-1/8"

75-1/4"

75-3/8"

75-1/2"

75-5/8"

75-3/4"

75-7/8"

76"

76-1/8"

76-1/4"

76-3/8"

76-1/2"

76-5/8"

76-3/4"

76-7/8"

77"

77-1/8"

77-1/4"

77-3/8"

77-1/2"

77-5/8"

77-3/4"

77-7/8"

78"

78-1/8"

78-1/4"

78-3/8"

78-1/2"

78-5/8"

78-3/4"

78-7/8"

79"

79-1/8"

79-1/4"

79-3/8"

79-1/2"

79-5/8"

79-3/4"

79-7/8"

80"

80-1/8"

80-1/4"

80-3/8"

80-1/2"

80-5/8"

80-3/4"

80-7/8"

81"

81-1/8"

81-1/4"

81-3/8"

81-1/2"

81-5/8"

81-3/4"

81-7/8"

82"

82-1/8"

82-1/4"

82-3/8"

82-1/2"

82-5/8"

82-3/4"

82-7/8"

83"

83-1/8"

83-1/4"

83-3/8"

83-1/2"

83-5/8"

83-3/4"

83-7/8"

84"

84-1/8"

84-1/4"

84-3/8"

84-1/2"

84-5/8"

84-3/4"

84-7/8"

85"

85-1/8"

85-1/4"

85-3/8"

85-1/2"

85-5/8"

85-3/4"

85-7/8"

86"

86-1/8"

86-1/4"

86-3/8"

86-1/2"

86-5/8"

86-3/4"

86-7/8"

87"

87-1/8"

87-1/4"

87-3/8"

87-1/2"

87-5/8"

87-3/4"

87-7/8"

88"

88-1/8"

88-1/4"

88-3/8"

88-1/2"

88-5/8"

88-3/4"

88-7/8"

89"

89-1/8"

89-1/4"

89-3/8"

89-1/2"

89-5/8"

89-3/4"

89-7/8"

90"

90-1/8"

90-1/4"

90-3/8"

90-1/2"

90-5/8"

90-3/4"

90-7/8"

91"

91-1/8"

91-1/4"

91-3/8"

91-1/2"

91-5/8"

91-3/4"

91-7/8"

92"

92-1/8"

92-1/4"

92-3/8"

92-1/2"

92-5/8"

92-3/4"

92-7/8"

93"

93-1/8"

93-1/4"

93-3/8"

93-1/2"

93-5/8"

93-3/4"

93-7/8"

94"

94-1/8"

94-1/4"

94-3/8"

94-1/2"

94-5/8"

94-3/4"

94-7/8"

95"

104"

104-1/8"

104-1/4"

104-3/8"

104-1/2"

104-5/8"

104-3/4"

104-7/8"

105"

105-1/8"

105-1/4"

105-3/8"

105-1/2"

105-5/8"

105-3/4"

105-7/8"

106"

106-1/8"

106-1/4"

106-3/8"

106-1/2"

106-5/8"

106-3/4"

106-7/8"

107"

107-1/8"

107-1/4"

107-3/8"

107-1/2"

107-5/8"

107-3/4"

107-7/8"

108"

108-1/8"

108-1/4"

108-3/8"

108-1/2"

108-5/8"

108-3/4"

108-7/8"

109"

109-1/8"

109-1/4"

109-3/8"

109-1/2"

109-5/8"

109-3/4"

109-7/8"

110-1/8"

110-1/4"

110-3/8"

110-1/2"

110-5/8"

110-3/4"

110-7/8"

111"

111-1/8"

111-1/4"

111-3/8"

111-1/2"

111-5/8"

111-3/4"

111-7/8"

112"

112-1/8"

112-1/4"

112-3/8"

112-1/2"

112-5/8"

112-3/4"

112-7/8"

113"

113-1/8"

113-1/4"

113-3/8"

113-1/2"

113-5/8"

113-3/4"

113-7/8"

114"

114-1/8"

114-1/4"

114-3/8"

114-1/2"

114-5/8"

114-3/4"

114-7/8"

115"

115-1/8"

115-1/4"

115-3/8"

115-1/2"

115-5/8"

115-3/4"

115-7/8"

116"

116-1/8"

116-1/4"

116-3/8"

116-1/2"

116-5/8"

116-3/4"

116-7/8"

117"

117-1/8"

117-1/4"

117-3/8"

117-1/2"

117-5/8"

117-3/4"

95-1/8"

95-1/4"

95-3/8"

95-1/2"

95-5/8"

95-3/4"

95-7/8"

96"

96-1/8"

96-1/4"

96-3/8"

96-1/2"

96-5/8"

96-3/4"

96-7/8"

97"

97-1/8"

97-1/4"

97-3/8"

97-1/2"

97-5/8"

97-3/4"

97-7/8"

98"

98-1/8"

98-1/4"

98-3/8"

98-1/2"

98-5/8"

98-3/4"

98-7/8"

99"

99-1/8"

99-1/4"

99-3/8"

99-1/2"

99-5/8"

99-3/4"

99-7/8"

100"

100-1/8"

100-1/4"

100-3/8"

100-1/2"

100-5/8"

100-3/4"

100-7/8"

101"

101-1/8"

101-1/4"

101-3/8"

101-1/2"

101-5/8"

101-3/4"

101-7/8"

102-1/8"

102-1/4"

102-3/8"

102-1/2"

102-5/8"

102-3/4"

102-7/8"

103"

103-1/8"

103-1/4"

103-3/8"

103-1/2"

103-5/8"

103-3/4"

103-7/8" x1020D2.2 - 07/05fbf

10125

10152

10179

10207

10234

10261

10289

10316

10343

10371

10398

10425

10452

10480

10507

10534

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11999

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13429

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13533

13559

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13714

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13791

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18606104-1/2"

105-1/4" 18700

105-3/8" 18715