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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection 9 Repair Inspection ❑ 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS IDDate of Overfill Prevention Equipment Inspection <br /> 10180781 8/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> United Pacific #5447 OFF <br /> Business Site Address City ZIP Code <br /> 1469 E Hammer Ln Stockton 95210 <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 /> Garrett Warren 1 ( 916 ) 991 - 1 100 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 8185019 10/2/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Veeder- Root B42126 exp . 1 -21 -21 OPW EVR 101018 exp . 6-5-21 <br /> - 111 , QVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION F;` IF, ' <br /> tispectlon Method b Manufacturer Gdidell`nes (Specify) : <br /> Used; <br /> p Industry' Code or' Ettgineerthg'Standard (Specify) . RP1200 <br /> IF <br /> ❑ Engineered Method (Specify) : <br /> IF F 1 01 <br /> Attacri the inspection procedures and ali documeritaiion required to deterni1he the results: <br /> # of Attached Pages <br /> TANK,lb: (By tank ii Umber, sfored product, efc.) T 1 � 1 rte : $ 9 T $ : 87 l`4 Diesel <br /> What i§ the tank inside diameter? (Inches) 120r - 120r' . 12Q1 0 ° <br /> Ior <br /> Is the fill pipifid secondarliy contained ? El Yes lid No d Yes 9 No n Yes d No ❑ Yes El No <br /> Is .theyent piping seebndarily contained ? ❑ Yes d No b Yes d No L] Yes 9 No ❑ Yes . ❑x No <br /> OF <br /> Overfill Prevention Equipment Manufacturers • opvv oPW OPW opw <br /> OF <br /> what Is the overfill prevention equipment response M Shuts Off Plow 9 Shuts Off Flow 9 Shuts Off Plow 0 Shuts Off Flow <br /> I <br /> eetivated ? Restricts Flow 130 Restricts Flow Restricts Plow d Restricts Flow <br /> (Check all that apply.) <br /> d A/V Alarm ` L] AN Alarm [i AN Alarm [j AIV Alarm <br /> Are flow restnctors installed on vent piping? Li Yes d No d Yes M No d Yes 0 No d Yes [E No <br /> At What level in the tank Is the overfill prevention set �l ,; <br /> to activate? (Inches from bottom of tank.) 105 105 <br /> What Is the percent capacity of the tank at Which the <br /> j ' overfill prevention equipment activdtes? 950/0 95 % <br /> If <br /> Is the overfill prevention in proper operating condition Yes i] Yes El yes F1 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 ResultsD Pass ElFail 9 Pass ElFail ❑ Pass 9 Fail ❑ Pass Q Fail <br /> OFFIFFIFFIFFIFFIFFIFFIFFIFFIFFOO <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <br /> Could not remove the 87 drop tube . Bucket will have to be cut out and replaced , and drop tube tested . The Diesel drop <br /> tube was removed , but the flapper was broken . Drop tube will need to be replaced . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CON DUbT11Nb16rHT&1WbPEtTTbNLS= - <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California ,C � e f o tions , Title 23 , <br /> Division 3 , Chapter 16, Section 2637. 2 and all the information contained herein is accurate. Nl�� � <br /> UST Service Technician Signature <br /> i If the facility has more components than this form accon1modates, additional copies of this page maybe at <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code G nat, PIT <br /> CERS d Usual <br />