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i <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection Repair Inspecfior-:.., ®36 Month Inspection <br /> - 1.FACICITYFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10402351 10/23/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARCO am/pm#83230 <br /> Business Site Addressify ZIP Code <br /> 1340 W. Colon Rd. -i�9V'Pr) IMENTAL H I 'ort 95366 <br /> 11. UNDERGROUND STORAGE TANCURVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Guadalupe Sanchez 925 470-0803 Ext. <br /> Contractorfrank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 4/8/2019 <br /> Overfill Prevention Equipment Inspection Training and Cert cations(List applicable certifications.) <br /> Veeder Root A30138 Exr)"res* 10/30/2019 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ®Manufacturer Guidelines(Specify)Veeder Root (Overfill Protection Testing CER-2018-02A) <br /> ❑Industry Code or Engineering Standard(Specify) <br /> ❑Engineered Method(Specify) <br /> Attach the Inspection procedures and all documentation required to determine the results. #of Attached Pages: 11 <br /> Tank ID:(By tank number,stored product,etc.) T1: 87 T2: 91 T3: Diesel <br /> What is the tank inside diameter?(Inches) 118 118 118 <br /> Is the fill piping secondarily contained? ®Yes ❑No ®Yes ❑No ®Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ®Yes ❑ No ®Yes ❑No ®Yes ❑No ❑Yes ❑No <br /> Veeder Root Veeder Root Veeder Root <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> (Check all that apply.) ®A/V Alarm ®AN Alarm ®AN Alarm ❑AN Alarm <br /> Are Flow restrictors installed on vent piping? ®Yes ❑No ®Yes ❑No ®Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention 98 99 99 <br /> set to activate?(inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 90 90 90 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating ®Yes ®Yes ®Yes ❑Yes <br /> condition to respond when the substance ❑No ❑No ❑No ❑No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ®Pass ❑Fail ®Pass ❑Fail 1 ®Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> All 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 equipment was Inspected in accordance with California Code of Regulations,title 23,division 3, <br /> chapter 16,section 2637.2 and all the Information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates,#didonat copies of this page may be attached. <br /> rRIK=rz*vvdn Fnu4mrrnPnt;d Rann MnnSvOom in=k1Pnrrhr Wnn I LCT=I IrAorrvry Zvi.tr rwu-tank Irr:=inhvnalinna!rsvia(jv mrli AN=Ai vBNn aril vias ni <br />