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01 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> (:FRS ID I flare of Overfill PrAvan}inn Fmilnmont Inenarrinn <br /> 11/8/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Unified Grocers, Inc. <br /> Business Site Address City ZIP Code <br /> 1990 Piccoli Rd. I Stockton 95215 <br /> ii, UNDERGROUND STORAGE TANK SER K_;_h 1 ECI HVIC:IAN II11F(JWA i IUN <br /> Name of US"t Service Technician Performing the Inspection(Print as shown on the ICC Certification) Phone# <br /> Jarrett Flewellyn (714)560-8222 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 588098 8028164 03-29-2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> OPW-0174949 <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): Tape Measure <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages <br /> I <br /> TANK ID:(By tank number,stored product,etc.) Diesel <br /> What Is the lank inside diameter?(Inches) 114 <br /> Is the fill piping secondarily contained? ❑Yes ❑x No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes ED No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW 71 SO <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply) ZRestricts Flow E]Restricts Flow [IRestricts Flow ❑Restricts Flow <br /> ❑AN Alarm ❑AIV Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 98" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V) ❑No(Specify in V.) ❑No(Specify in V. ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention inspection Results ❑x Pass ❑Fail I ❑Pass ❑Fail I ❑Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail"must be explained in this section. Any additional comments may also be provided here. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THiS INSPECTION <br /> 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 the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facfifty has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Usual <br />