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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 /> CERS ID Date of Overfill Prevention Equipment Inspection <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. Stockton 95215 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Jarrett Flewellyn 1(714)560-8222 <br /> Contractor I Tank Tester License# F8028164 <br /> CC Certification# ICC Certification Expiration Date <br /> 588098 103-29-2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Gilbarco Veeder Root-B36959 <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 /> _ r <br /> TANK ID:(By tank number,stored product,etc.) Diesel <br /> What is the tank inside diameter?(Inches) 114 <br /> Is the fill piping secondarily contained? ❑Yes 9 No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes 9 No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) Gilbarco <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.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> 0 AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 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.) 95" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90% <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 0 Pass ❑Fail ❑Pass ❑Fail ❑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 /> 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 the information contained herein is accurate. <br /> UST Service Technician Signature <br /> 9&"ff" <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Carrfomia Environmental Reportirx System,ID=Identification,UST=Underground Storage Tank,ICC=International Code oundl,AN=Audible and Visual <br />