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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 <br /> 10180519 Date of Overfill Prevention Equipment Inspection <br /> 8/27/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Speedway 1486 <br /> Business Site Address City ZIP Code <br /> 13975 E Hwy 88 Lockeford 95237 <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 /> Kristopher Bell (408) 971 -2445 <br /> Contractor ! Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 10/29/21 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications,) <br /> F . F. # 1004933708 <br /> Veeder Root # B33709 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify) : <br /> Used : Veeder Root <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,) 1 - Regular 2-Premium 3- Diesel <br /> What is the tank inside diameter? (Inches) 1183/8 1183/8 1183/8 <br /> Is the fill piping secondarily contained ? ❑✓ Yes ❑ No 0 Yes ❑ No <br /> ❑✓ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑,/ Yes ❑ No © Yes ❑ No <br /> ❑✓ Yes ❑ No F1 Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ Restricts Flow ❑ Restricts Flow <br /> © A!V Alarm ® AN Alarm ® AN Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑✓ No ❑ Yes ❑✓ No ❑ Yes <br /> Q No El Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank) 99 . 1 /8" 98, 5/8° 99. 7/8 <br /> What is the percent capacity of the tank at which the — <br /> overfill prevention equipment activates ? 90" 90" 90" <br /> Is the overfill prevention in proper operating condition ® Yes ® Yes <br /> to respond when the substance reaches the ® Yes EJ Yes <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 ® Pass ❑ Fail ® Pass ❑ Fail © Pass ❑ Fail ❑ Pass <br /> ❑ Fail <br /> V. COMMENTS <br /> Any 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 , <br /> Division 3, Chapter 16 , Section 2637 .2 and all the information contained herein is accurate. <br /> UST Service Technician Signature t � <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />