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UN '11511, UND STORAGE TANK , <br /> 0YERF11.I RREI/ENTiC►N IwQI!(PMSNT INSPECTIN REP®RT.F'qRM <br /> Type of Action: ❑Installation Inspection ❑Repair Inspection 0 36 Month Inspection <br /> V11:FACILlTYINFCIRMAiIt)W <br /> i <br /> CERS ID: Date of Inspection: <br /> 10181559 8/2/201.8 <br /> Business Name(Same as Facility Name or DBA): <br /> Kaiser Foundation - Manteca <br /> i <br /> Business Site Address: City: Zip: <br /> 1777 W Yosemite Ave Manteca 95337 <br /> Vltl UNI3ERGRt3U11:SYARAGE TANK';SER1l#CE TEGHN#GIAN tN1=0RIV1AT10N„ <br /> _. . <br /> Name of UST Service Technician(Print as shown on ICC Certification): Phone: <br /> Jeff Badders (949) 306-1890 <br /> Contractor/Tank Tester License#: ICC Certification Number: <br /> 808313 I 5252456 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List all applicable certifications): <br /> Veeder-Root A20392 R E C 1 <br /> IX UNFrGROl1N `STC}# AG _"t ANK SERu�C TFGHN#G1AN (qN <br /> Test Method Used ❑ Manufacturer Guidelines(Specify): <br /> Q Industry Code or Engineering Standard(Specify):PEI RP 1200 <br /> ❑ Engineered Method(Specify): <br /> YAtiached ages: <br /> Attach the inspection procedures and all documentation required to determine the results. <br /> Tank ID (by tank number, product, etc.) T2 Diesel <br /> Tank diameter(Inches): 92" <br /> Is fill piping secondarily contained? ❑Yes Fol No ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> Is vent piping secondarily contained? e❑ Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> Overfill Prevention Equipment OPW <br /> Manufacturer(s): PSL <br /> What is the overfill prevention ❑ Shuts off Flow ❑ Shuts off Flow ❑ Shuts off Flow ❑ Shuts off Flow <br /> equipment response when activated? ❑■ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply) ❑A1V Alarm ❑AIV Alarm ❑AIV Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑o No ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑ No <br /> At what level In tank will overflow prevention 8)„ <br /> activate in inches from tank bottom)? <br /> -What is the percent capacity of tank at which 93% <br /> overflow prevention activates? <br /> Is the overfill prevention in proper ■❑Yes ❑Yes ❑Yes ❑Yes <br /> operating condition to respond when <br /> substance reaches the appropriate ❑ No* ❑ No* ❑ No* ❑ No* <br /> level? '(Specify In section V) `(Specify In section V) '(Specify In section V) `(Specify In section V) <br /> X.SUMMAR1i'O ,INSPETION RESULTS <br /> Overfill Prevention Inspection Results: Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> XI;CON#MENTS , <br /> All Items marked"Fail'must be explained in this section.Any additional comments may also be provided here: <br /> X#C.GERTlFICATION BY US C SERVGE TEC_HNlGt ►N.GONDUCTfNG THIS iINSPEGT#OIV. <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 information contained herein is true and accurate. <br /> UST Service Technician Signature <br /> Revision Date:4/11/2018 <br />