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UNDERGROUNDS ORALE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection FACILITY INFORMATION _ . CERS IQ 10184805 i I Date of Overfill Prevention Equipment inspection 10 / 10/2018 i Business Name (Same as Facility Name or DBA-Ooing Business As) Rancho San Miguel Business Site Address City ZIP Code - - _� Lodi 4`95240 610 Cherokee Lane 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) j 7Phoo .� Raamon Frazier (408 ) 971 -2445 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date i 485184 8020732 2/7/2019 Overfill Prevention Equipment inspection Training and Certifications (List applicable certifications.) ViR ( ATG ) - 637362 r n ; OVERFILL PREVENTION EQUIPMENT INSPECTION INOftMAtION _-- 'Inspection Method r ❑x Manufacturer Guidelines (Specify) : Veeder Root 10U f � Used: _ ❑ Industry Code or Engineering Standard (Specify) t [ V r- 7ft tr,71 s ft L7 �. � " . ❑ Engineered Method (Specify): Attach the Inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) T1 - 87 T1 - 91 G _ What is the tank inside diameter? (Inches) 112.O0 ( 1 12 . 00 Is the fill piping secondarily contained? ZYes E] No 3 E) Yes ❑ No E) Yes ❑ No CJYes ❑ No Is the vent piping secondarily contained? i ® Yes ❑ No 9 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No � Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off now ❑ Shuts Off Flow Ii ❑ Shuts Off Flow when activated ? (Check all that apply.) E] Restricts Flow EJ Restricts Flow E] Restricts Flow ❑ Restricts Flow ( Q AiV Alarm O AN Alarm i ❑ AN Alarm " E] AN Alarm Are flow restrictors installed on vent piping? ❑ Yes [I No E] Yes ❑ No ❑ Yes ❑ No II ❑ Yes E] No i At what level in the tank is the overfill prevention set ! 1 3027 4568 11 r to activate? (Inches from bottom of tank.) What is the percent capacity of the lank at which the i overfill prevention equipment activates? 90 % _ 90 % ;! Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes i ElYes El Yes I' to respond when the substance reaches the appropriate level? EJ No (Specify in V ) ❑ No (Specify in V ) E] No (Specify in V,) ❑ No (Specifyin V ) {,.-- .. n V. IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fad ® Pass ❑ Fail ❑ Pass ❑ Fail 0 Pass E] Fail _ _V . COMMENTS _ Any items marked 'Fal " must be explained in this section. Any additional comments may also be provided here. i vim CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION _ _. --- .___ _ . - - _-� _. _ _- __ ._ ___ . hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , Title 23, Division 3, Chapter 16 , Section 2637 .2 and all the information contained herein is accurate , UST Service Technician Signature r If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Envin rrnental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intematbnal Code Council, AN = Audbte and Usual E I I