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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 /> 10146143 5/7/20 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Costco#1031 Manteca <br /> Business Site Address City ZIP Code <br /> 2440 Daniel St. Manteca 195337 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Isaac Anderson 209 532-7320 Ext. <br /> ContractoNTank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CA 623541/09-1749 8146912 06/12/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> V t Level IV#1336878 Exp 10/22/20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: N Manufacturer Guidelines(Specify)Remy A Tank gauge. bring fuel float to 90% <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 87A T2 87B T3 91 T4 Additive <br /> What is the tank inside diameter?(inches) 120 120 120 48 <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 IM Yes ❑ No ®Yes ❑No <br /> Veeder-Root 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.) <br /> ®AN Alarm ®AN Alarm ®AN Alarm ®AN Alarm <br /> Are flow restrictors installed on vent piping? ®Yes ❑No ®Yes ❑ No ®Yes ❑No M Yes ❑ No <br /> At what level in the tank is the overfill prevention 100.5 100.5 100.5 40 <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which I 90 90 90 90 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating M Yes ®Yes M 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 ❑ ® Pass ❑ Fail 1 ® 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 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,division 3, <br /> chapter 16,section 2637.2 and all the Information c tained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more component an 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,AN=Audible and visual <br />