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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 CI Repair Inspection III 36 Month Inspection <br />I. FACILITY INFORMATION <br />CEPS ID Inn!. or (-)‘..rfIli prAventInn Equipment Inspection <br />I 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 />1 City <br />Stockton <br />ZIP Code <br />95215 <br />ii. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMA I ION <br />Name of US1 Service Technician Performing the Inspection (Print as shown on the ICC Certification.) <br />Jarrett FleWellyn <br />Phone if <br />(714) 560-8222 <br />Contractor / Tank Tester License if <br />588098 <br />ICC Certification if <br />8028164 <br />ICC Certi ication Expiration Date <br />03-29-2019 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />OPW - (11749451 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />0 Manufacturer Guidelines (Specify): Tape Measure <br />0 Industry Code or Engineering Standard (Specify): <br />11 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 />VVhat Is the tank Inside diametei? (Irrehes) 114 <br />Is the fill piping secondarily contained? 0 Yes E No Yes 1:1 No 0 Yes 0 No Yes 0 No <br />Is the vent piping secondarily contained? 0 Yes El No EI Yes El No II Yes • No Yes CI No <br />Overfill Prevention Equipment Manufacturer(s) OM 71S0 <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />0 Shuts Off Flow <br />CI Restricts Flow <br />0 AN Alarm <br />El Shuts Off Flow <br />M Restricts Flow <br />M AN Alarm <br />I=I Shuts Off Flow <br />X Restricts Flow <br />0 AN Alarm <br />Shuts Off Flow <br />12 Restricts Flow <br />CI AN Alarm <br />Are flow restrictors installed on vent piping? M Yes 2 No 0 Yes IN No El Yes 0 No 0 Yes 0 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? <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />El Yes <br />El No (Specify in V.) <br />Yes <br />0 No (Specify in V.) <br />P Yes <br />El No (Specify in V.) <br />0 Yes <br />El No (Specify in V.) <br />IV. SUMMARY OF INSPECTION RESULTS <br />Overfill Prevention Inspection Results 1 0 Pass 0 Fail 1 0 Pass E] Fail I C] Pass IN Fail 1 Pass I 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 />Pcwrete 7eeevetifs <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