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, <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <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 /> 10141507 9/13/2018 <br /> Business Name(Same as FacililyName or DBA-Doing Business As) <br /> Frontier- Manteca <br /> Business Site Address City ZIP Code <br /> 430 West Center St Manteca 95336 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name or UST Service Technician Performing the Inspection(Print as shown on the/CC Certification.) Phone# <br /> Raul Ochoa 1 (714)434-9995 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 734854 8029372 11/13/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> EBW(FFS)#1011753710 Veeder Root#1334397 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ®Manufacturer Guidelines(Specify): 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 8 <br /> TANK ID.(By tank number,stored product,etc.) T1 Diesel T1 Diesel <br /> What is the tank inside diameter?(Inches) 92„ 92" <br /> Is the fill piping secondarily contained? ®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) EBw 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? ❑Yes ❑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.) 72.5" �e 77 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 78% 90% <br /> Is the overfill prevention in proper operating condition ®Yes ®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 HE Pass ❑Fail ❑x Pass []Fail ❑Pass ❑ Fail I ❑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 /> Unable to remove 4"bung on ball float to inspect-seized on. RECEIVE[) <br /> OCT 2 3 2018 <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with Califor ' m m p-, <br /> Division 3,Chapter 16,Section 263A2 and all the information c ntained herein is accurate. <br /> UST Service Technician Signature Kl-z� DE RTMENT <br /> If the facility has more components t n this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AA/=Audible and Visual <br /> UN-109 www.unidoes.org 1M-Rev.06/14/18 <br />