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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑x Repair Inspection ❑ 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180781 1 /8/2020 Business Name (Same as Facility Name or DBA-Doing Business As) United Pacific #5447 Business Site Address City ZIP Code 1469 E Hammer Ln Stockton 95210 I1 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) Phone # Garrett Warren Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date CSLB#803616 8185019 9/20/2021 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Veeder- Root B42126 exp . 1 -21 -21 OPW EVR 101018 exp . 6-5-21 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (Specify) : Used : ❑x Industry Code or Engineering Standard (Specify) : RP1200 ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, storedproduct, etc) T1 : 91 T2 : 89 T3 : 87 T4 : Diesel What is the tank inside diameter? (Inches) 120 120 " 120 " 120" Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes Z No Is the vent piping secondarily contained? ❑ Yes 2 No ❑ Yes n No ❑ Yes El No ❑ Yes 0 No Overfill Prevention Equipment Manufacturer(s) oPw oPW opw oPW What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow Shuts Off Flow when activated ? ❑x Restricts Flow �9 Restricts Flow Z Restricts Flow n Restricts Flow (Check all that apply.) ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes [E No ❑ Yes H No ❑ Yes 0 No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 104 . 75 „ 104 . 75 „ 104 . 75 „ 104 . 75 „ What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 % 94 % 94 % 94 % Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes 0 Yes El Yes to respond when the substance reaches the appropriate level? El No (Specify in V.) [INo (Specify in V.) El No (Specify in V) El No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Q Pass ❑ Fail ❑x Pass ❑ Fail 0 Pass ❑ Fail 0 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 equipmentwas inspected in accordance with California Code of Regulations , Title 233 Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form mccommodates, additional copies of this page maybe attached. CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual