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01 <br />UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action El Installation Inspection 0 Repair Inspection 0 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 <br />1990 Piccoli Rd. <br />City <br />Stockton <br />ZIP Code <br />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.) <br />Jarrett Flewellyn <br />Phone # <br />(714) 560-8222 <br />Contractor! Tank Tester License # <br />588098 <br />ICC Certification # <br />8028164 <br />ICC Certification Expiration Date <br />03-29-2019 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />Gilbarco Veeder Root - B36959 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />0 Manufacturer Guidelines (Specify): Tape Measure <br />Industry Code or Engineering Standard (Specify): <br />MI Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <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? CI Yes El No Yes • No IN Yes III No ID Yes 0 No <br />Is the vent piping secondarily contained? 0 Yes 0 No Yes 0 No ITI Yes 0 No 0 Yes D No <br />Overfill Prevention Equipment Manufacturer(s) Gilbarco <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply) <br />Shuts Off Flow <br />El Restricts Flow <br />El AN Alarm <br />El Shuts Off Flow <br />0 Restricts Flow <br />AN Alarm <br />El Shuts Off Flow <br />D Restricts Flow <br />0 AN Alarm <br />IN Shuts Off Flow <br />D Restricts Flow <br />a AN Alarm <br />Are flow restrictors Installed on vent piping? M Yes 12 No 0 Yes IN No U Yes IN No 0 Yes IN 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? 900/0 <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />0 Yes <br />0 No (Specify in V.) <br />0 Yes <br />0 No (Specify in V.) <br />0 Yes <br />0 No (Specify in V.) <br />0 Yes <br />0 No (Specify in V.) <br />IV. SUMMARY OF INSPECTION RESULTS <br />Overfill Prevention Inspection Results IMI Pass III Fail M Pass II Fail CI Pass • Fail 0 Pass 0 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 18, Section 2637.2 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />fainert ee.eveikpc <br />If the facility 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 Visual