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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page I of 1) Type of Action ❑Installation Inspection ❑Repair Inspection R]36 Month Inspection I. FACILITY INFORMATION CERS ID Dale of Overfill Prevention Equipment Inspection 1/22/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Arco 6080 Business Site Address City ZIP Code 85 E. Louise Ave 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# David Rouse (925) 551-7555 Contractor f Tank Tester License# ICC Certification# ICC Certification Expiration Date 220793 8292530 6/28/2019 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certificalions) N/A ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑Manufacturer Guidelines(Specify) Used ❑Q Industry Code or Engineering Standard(Specify) Tank Chart, Veeder Root, Tape Measure ❑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 Unleaded T2 Premium T3 Diesel What is the tank inside diameter?(Inches) 119.60 119.60 119.60 Is the fill piping secondarily contained? 0 Yes ❑No Q Yes ❑No Yes ❑No ❑Yes ❑No is the vent piping secondarily contained? 0 Yes ❑No 0 Yes ❑No [E Yes ❑No ❑Yes ❑No Overfill Prevention Equipment Manufacturers) 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 ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow 0 AfV Alarm I]AIV Alarmx❑AIV Alarm ❑A/V Alarm Are flow resinctors installed on vent piping? ❑Yes []No ❑Yes i]No ❑Yes 2 No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank) 100 1/8" 99 1/2 991/4 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 ❑x Yes ❑x Yes ❑x Yes ❑Yes to respond when the substance reaches the appropriate level? ❑No(Specify in V.) ❑No(Specify in V} ❑Noecif S ( p y in V) ❑No(Specify in V) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results 0 Pass ❑Failx❑Pass x❑Fail I ❑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 WormaMin contained herein is accurate. UST Service Technician Signature If the facility has more components fh this form accommodates,additional copies of this page maybe attached. CERS=Caldonia Erm4orvrnenlal Reportng System,ID=Identification.UST=Underground Storage Tank,ICC=irdemabonaf Code Council.AN=Audible and Visual