Laserfiche WebLink
20202384 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181087 8/24/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Arco 2093 <br /> Business Site Address City ZIP Code <br /> 3425 Tracy Blvd Trac 95376 <br /> It. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification) Phone# <br /> Elodio Sanchez (925) 551-7555 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 220793 8887127 8/7/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certi(calions) <br /> Veeder Root Cert# B41204 Exp. 7/4/2022 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify) <br /> Used Tank Chart, Veeder Root Manual, Tape Measure <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 /> TANK ID:(By lank number,stored product,etc) T1-87 T2-87 T3-87 T4-91 <br /> What is the tank inside diameter?(Inches) 90 90 90 90 <br /> Is the fill piping secondarily contained? K <br /> ❑Yes ❑No Q Yes ❑No []Yes ❑No I]Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes El No <br /> [D Yes i]No El Yes [J No ❑Yes Q No <br /> Overfill Prevention Equipment Manufacturer(s) Vender Root Vroocr Ruor Vcrdar Root Vmder Roof <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 /> (]AN Alarm ❑x AN Alarm AfV AlarmxQ AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes El No ❑Yes 0 No ❑Yes 3 No ❑Yes [E No <br /> At what level in the lank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 75 75 75 75 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 90 90 90 <br /> Is the overfill prevention in proper operating condition (E Yes Q Yes Q Yes Q 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 Q Pass ❑Fail 19 Pass ❑Fail I ❑Pass ❑Fail 0 Pass ❑Fail <br /> V. COMMENTS <br /> Any items marked"Fail"must be explained in thrs section. Any addi(ionaf comments may also be provided here <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmen s inspected in accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 263LAVind all the I rmatio contained herein is accurate. <br /> UST Sery ce Technician Signature <br /> -- �& S.0" <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Erwornnnental Reporting System ID=tdentifx;a ,UST=Underground Storage Tank.ICC=Irdemational Code Council AN=Audibie and Visual <br />