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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page -I of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection N 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 1 /3/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Colonial Energy Business Site Address City ZIP Code 192 Lathrop Road lathrop 95330 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Anthony Reyes ( 916 ) 373 - 1166 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8293772 9/ 16/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) _ OPW UST Phase 1 EVR Tech# 103920 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION JAN 10 21119 Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : OPW Install & Maintenance Guidelines ❑ Industry Code or Engineering Standard (Specify) : LINIVIt ` M > , NT ps TO .- ❑ 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.) 87 Master 87 Slave 91 Gasoline Diesel What is the tank inside diameter? (Inches) 113 . 75 113 . 75 113 . 75 110 . 75 Is the fill piping secondarily contained ? ❑x Yes ❑ No x❑ Yes ❑ No R Yes ❑ No R Yes ❑ No Is the vent piping secondarily contained? ❑ Yes R No ❑ Yes R No ❑ Yes EINo ❑ Yes R No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW OPW What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow Z Shuts Off Flow 0 Shuts Off Flow when activated ? (Check all that apply.) ❑ Restricts Flaw E] Restricts Flow El Restricts Flow El Restricts Flow ❑ A/V Alarm El A/V Alarm El A/V Alarm E] A/V Alarm Are flow restrictors installed on vent piping ? ElYes E No ElYes R No ElYes R No ElYes R No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 99 . 75 102 . 125 99 . 875 97 . 625 What is the percent capacity of the tank at which the overfill prevention equipment acts ate ? 92 / 94 / 92 / 92 / Is the overfill prevention in proper operating condition ❑x Yes R Yes ❑x Yes ❑x Yes to respond when the substance reaches the pecify in V.) ❑ No (Specify in V.) El (Specify in V.) E] No (Specify in V.) appropriate level ? El No (S IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results (] Pass ❑ Fail ❑x Pass ❑ Faiij ❑x Pass ❑ Fail ❑Q Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas 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 A ��r� If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual