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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 o;Inspection; Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month 1 . FACILITY INFORMATION CERS ID 10181387 Date of Overfill Prevention Equipment Inspection 1 / 15/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Ryder Truck Rental Business Site Address City ZIP Code 3633 Duck Creek Dr. Stockton 95215 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Robert Henninger 1 (408 ) 942-8686 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 396575 5252265-UT 7/ 13/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Veeder- Root - A25027 04/15/ 19 t III . OVERFILL PREVENTION EQUIPMENT INSPECTIO I OORkATidiu Inspection Method ❑ Manufacturer Guidelines (Specify): r Used : Q Industry Code or Engineering Standard (Specify): RP- 1200 F ❑ Engineered Method (Specify): fc. / r� 0N r , c i i �z � i fl Attach the inspection procedures and all documentation required to determine the results. #o Attached Pages TANK ID : (By tank number, stored product, etc.) T1 : Diesel T2 : Diesel T3 : Motor Oil T4 : Used Oil What is the tank inside diameter? (Inches) 96 96" 96" 64 " Is the fill piping secondarily contained? ❑x Yes ❑ No El Yes ❑ No n Yes ❑ No ❑x Yes ❑ No Is the vent piping secondarily contained ? ❑x Yes ❑x No ❑x Yes ❑ No 0 Yes ❑ No 0 Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Veeder-Root Veeder-Root Veeder-Root Veeder-Root I What is the overfill prevention equipment response E] Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? (Check all that apply.) ElRestricts Flow E] Restricts Flow [IRestricts Flow ❑ Restricts Flow Q AN Alarm 0 AN Alarm x❑ AN Alarm ❑x AN Alarm Are flow restrictors installed on vent piping? ❑ Yes ❑x No ❑ Yes E No ❑ Yes 9 No ❑ Yes [ig No At what level in the tank is the overfill prevention set „ „ „ „ E to activate? (Inches from bottom of tank.) 80 . 5 80 . 5 80 . 5 53 . 5 [ What is the percent capacity of the tank at which the E overfill prevention equipment activates? 90 % 90 % 90 % 90 % Is the overfill prevention in proper operating condition ❑x Yes9 Yes 9 Yes FRI Yes to respond when the substance reaches the appropriate level? El No (Specify in V.) El No (Specify in V.) El No (Specify in V.) El No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 9Pass El Fail 9Pass ❑ Fail ❑x Pass ❑ Fail Pass ❑ Fail V. COMMENTS Any items marked "Fail" 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 equipment was inspected in accordance with California Code of Regulations , Title 23, Division 3, Chapter 16, Section 2637 .2 and all the information contained herein is accurate. UST Service Technician Signature C If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual i UN -109 www.unidocs.org 1 /1 - Rev. 06/14118 II