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01 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 11/8/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Unified Grocers, Inc. <br /> Business Site Address City ZIP Code <br /> 1990 Piccoli Rd. Stockton 95215 <br /> Il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the/CC Certification.) Phone# <br /> Jarrett Flewellyn (714)560-8222 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 588098 8028164 03-29-2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Gilbarco Veeder Root-B36959 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Methodx❑Manufacturer Guidelines(Specify): Tape Measure <br /> Used: <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 Pages <br /> TANK ID: (By tank number,stored product,etc.) Diesel <br /> What is the tank inside diameter?(Inches) 114 <br /> Is the fill piping secondarily contained? ❑Yes 0 No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes Z No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) Gilbarco <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply) ❑ Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑x AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors Installed on vent piping? ❑Yes (R No ❑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.) <br /> 95" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? R ❑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 ❑x Pass []Fall ❑Pass ❑Fail I ❑Pass ❑Fail ❑ Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail'must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I 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 /> 574w4 __ _ _ <br /> If the facility has more components than this form accommodates,additional copies of this page maybe attached. <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />