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20200037 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 of i) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181263 1/21/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Arco 6080 <br /> Business Site Address City ZIP Code <br /> 85 E Louise Ave Lathrop 95330 <br /> ll. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification) Phone# <br /> (925) 551-7555 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 220793 8716847 4/8/2021 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications) <br /> Veeder Root Cert#1348849 Exp. 414/2021 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Manufacturer Guidelines(Specify) <br /> Used: Tank Chart, Veeder Root, Tape Measure <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 Page, <br /> TANK ID:(By tank number,stored product,etc) 87 T1 91 T2 DSL T3 <br /> What is the tank inside diameter?(Inches) 1195/8 1195/8 1195/8 <br /> Is the fill piping secondarily contained? 0 Yes ❑No El Yes []No (]Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? Z Yes ❑No 111 Yes ❑No 2 Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufaeturer(s) vecdor Root veedpr Root v: I.,Root <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuls Off Flow <br /> ❑Shuts Off Flow El Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> [J AN Alarm Q A/V Alarm 0 AN Alarm ❑AN Alarm <br /> Are flow restriclors installed on vent piping? ❑Yes (]No ❑Yes 0 No ❑Yes Q No ❑Yes ❑No <br /> At what level in the lank is the overfill prevention set <br /> to activate?(Inches from bottom of lank.) 100 99 3/8 991/8 <br /> What is the percent capacity of the lank at which the <br /> overfill prevention equipment activates? 90 90 90 <br /> Is the overfill prevention in proper operating condition ❑x Yes Q Yes (]Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑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 r❑x Pass []Fail E Pass ❑Fail I Z Pass ❑Fail ❑Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked"Fail"must be explained in this section. Any additional comments may also be pro.ided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> 1 hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, <br /> Division 3, 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,additional copies of this page may be attached. <br /> CERS=Calftrm a Environmental Reporting System,10=Identifiration.UST=Urdergmund Storage Tank.ICC=International Code Counal.AN=Audible and t:isual <br />