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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10156809 11 /22/19 Business Name (Same as Facility Name or DBA-Doing Business As) Safeway Business Site Address City ZIP Code 2802 Country Club Blvd , Stockton 95204 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Brian McPheely {916 ) 649-8670 Contractor / Tank Tester License # IGC Certification # ICC Certification Expiration Date 485184 8822062 1119! 19 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) 1014303708 / B36745 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (Specify) : Used : ® Industry Code or Engineering Standard (Specify) : Veeder Root ❑ 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 T2 : 91 T3 : Diesel What is the tank inside diameter? (Inches) 119 . 5 119 . 5 119 . 5 Is the fill piping secondarily contained? Q Yes ❑ No © Yes ❑ No © Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes © No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) ❑ Restricts Flow El Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ® AIV Alarm ® AN Alarm ® AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes © No ❑ Yes © No ❑ Yes ® No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (inches from bottom of tank.) 100 . 5 10015 100 . 5 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90% 90 % 90% Is the overfill prevention in proper operating condition ® Yes ® Yes ® Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V) [:3 No (Specify in V) [3 No (Specify in V) ❑ No (Specify in V) IV, SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ 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 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 �_� 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