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r <br /> UNDERGROUND .STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> TypeAt ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection <br /> im FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10156819 2/14/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Safeway #2707 <br /> Business Site Address City ZIP Code <br /> 6425 N . Pacific Ave . Stockton 95207 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Steven White 1 (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8898679 5/10/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> 10 16243710 1 C24135 <br /> Ill . OVERFILL PREVENTION , EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify) : <br /> Veeder Root <br /> Used : <br /> ® Industry Code or Engineering Standard (Specify) : PEI 1200 <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) T1 - Regular T2 - Premium T3 - Diesel <br /> What is the tank inside diameter? (Inches) 119. 75" 119. 75" 119 . 75" <br /> Is the fill piping secondarily contained? 0 Yes ❑ No ® Yes ❑ No © Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ® Yes ❑ No © Yes ❑ No © Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Ball Floats / Modem Welding Ball Floats / Modem Welding Ball Floats / Modem Welding <br /> Veeder Root Veeder Root Veeder Root <br /> What is the overfill prevention equipment response ® Shuts Off Flow ® Shuts Off Flow ® Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow E] Restricts Flow El Restricts Flow <br /> ® AN Alarm ® AN Alarm ® AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? 0 Yes ❑ No 0 Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 106. 5 106. 5 107. 5 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93 . 98% 93 . 97% 94. 63 <br /> Is the overfill prevention in proper operating condition ® Yes ® Yes ® Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? P ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may a provided here. <br /> F . <br /> MAR tb 2013 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance witf ;aifornGnd.'e of Rbgulatoris, TItIe 23, <br /> Division 3, Chapter 16 , Section 2637.2 and all the information contained herein is accurate. - f <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> E CERS = Cardomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br /> i <br />