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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) TypeAt ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10120456 1 /3/20 Business Name (Same as Facility Name or DBA-Doing Business As) Safeway 2707 Business Site Address City ZIP Code 6425 Pacific Ave Stockton 95207 Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Steven White (408) 971 -2445 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 485184 8898679 5/10/20 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) j e F . F . # 1016243710 VR # C24135 BE 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATIO Inspection Method ® Manufacturer Guidelines (Specify) : Veeder Root Used : ❑ Industry Code or Engineering Standard (Specify) : ENVIRO 1 r4s ` N11 a ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 91 Diesel What is the tank inside diameter? (Inches) 120 120 120 is the fill piping secondarily contained? ✓❑ Yes ❑ No ® Yes ❑ No ❑✓ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? 0 Yes ❑ No © Yes ❑ No ❑✓ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root TLS 350 TLS 350 TLS 350 What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? ❑ (Check all that apply.) ❑ Restricts Flow Restricts Flow Restricts Flow ❑ Restricts Flow ® A/V Alarm ® A/V Alarm ® AIV Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping? ❑ Yes ❑✓ No ❑ Yes ❑✓ No ❑ Yes ® No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 18 , 066 91033 91043 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 90 90 Is the overfill prevention in proper operating condition ® Yes ® Yes ® Yes ❑ Yes to respond when the substance reaches the El level? No (Specify in V.) ❑ No (Specify in V.) El No (Specify in V.) El No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail I ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. All Overfills set to 90% . Audio and Visual Working . Removed All Ball Floats , VL CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 1 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 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 Visual