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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 /> 10181433 3/14/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Unocal No . 25 <br /> Business Site Address City ZIP Code <br /> 2701 West March Lane Stockton 95219 <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 /> Steven White 1 (408) 971 -2445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8898679 5/ 10/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> 1016243710 / C24135 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify) : <br /> 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 <br /> TANK ID : (By tank number, stored product, etc.) T1 - 87 Octane T2 - 91 Octane T3 - Diesel <br /> What is the tank inside diameter? (Inches) 111 . 5" 111 . 5' 95 . 75" <br /> Is the fill piping secondarily contained ? ❑ Yes 0 No ❑ Yes ❑✓ No ❑ Yes Q No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑✓ No ❑ Yes © No ❑ Yes 0 No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Ball Floats / Joor Manufactunn Ball Floats / Joor Manufacturing Ball Floats / Joor Manufacturing <br /> Veeder Root Veeder Root Veeder Root <br /> What is the overfill prevention equipment ❑ 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 E] Restricts Flow <br /> m AN Alarm ® AN Alarm ® AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? 21 Yes ❑ No Z 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.) 93 . 25" 92 . 75' 77 . 5' <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 . 24% 88 . 90% 86. 76% <br /> Is the overfill prevention in proper operating condition ® Yes ® Yes ® Yes ❑ Yes <br /> to respond when the substance reaches the <br /> El level? No (Specify in V) El No (Specify in V.) El No (Specify in V.) El No (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> aaaai <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® 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 /> 1 <br /> d <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TH14 INSECCii <br /> I hereby certify that the overfill prevention equipmentwas 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 acculU41 HE= AL <br /> UST Service Technician Signature vroeaa� 1 DEPARTMENT <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />