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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 /> 10182265 10/10/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> ARCO AM PM#82602 <br /> Business Site Address City ZIP Code <br /> 2430 Joe Pombo Pkwy. Tracy 95376 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Guadalu a Sanchez 925 470-0803 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1005444 5250451 14/8/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Veeder Root A30138 Ex6ress 10/30/2019 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ©Manufacturer Guidelines(Specify)Veeder Root Overfill Protection TeStIna CEB 2018-02A <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.) T1: 87 Master T2: 87 Syphon T3: 91 <br /> What is the tank inside diameter?(Inches) 120 120 120 <br /> Is the fill piping secondarily contained? EI Yes ❑No ®Yes ❑ No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ® No ❑Yes ®No ❑Yes ❑No <br /> Veeder Root Veeder Root Veeder Root <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ® Restricts Flow ® Restricts Flow ®Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ®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 97 98 97 <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 90 90 90 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating ®Yes ®Yes ©Yes ❑Yes <br /> condition to respond when the substance ❑No ❑ No ❑No ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results © Pass ❑Fail 11 ® Pass ❑Fail ®Pass ❑Fail [:]Pass ❑Fail <br /> V. COMMENTS <br /> All items marked"Fail'must be explained in this section. Any additional comments may also be provided he <br /> t <br /> NOV n P �n,o <br /> ENVIRGAIAENT . <br /> I1r n� .__d tNLTH <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,division 3, <br /> chapter 16,section 2637.2 and all the information contained herein is accurate. <br /> UST Service Techrtifan Signature <br /> If the facility has more compo ents than thi form accommodates,additional copies of this page may be attached. <br /> r:FRC=r nlifnmin Fnvimnmantal Parvvtinn Cvctpm In=Wcntifirn inn I LST=I Inr,amms inri ctnranp tank Ir.r:=IntPmafinnal r'.rvip riv inril AN=Ai uiihip and vici val <br />