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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 /> 7/31/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Fedex Ground <br /> Business Site Address City ZIP Code <br /> 5655 Hood Way Tracy 95377 <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 /> Robert Henninger (408) 942-8686 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 396575 5252265-UT 6/21/2021 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Veeder-Root Certification: A25027 expires: 03/31/21 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: Veeder Root <br /> ❑x Industry Code or Engineering Standard(Specify): RP1200 <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 2 <br /> TANK ID: (By tank number,stored product,etc.) T1: Diesel T2: Diesel <br /> What is the tank inside diameter?(Inches) 118-3/8" 118-3/8" <br /> Is the fill piping secondarily contained? ❑x Yes ❑ No 0 Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑x Yes ❑ No i]Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) ❑ ❑ ❑ <br /> Restricts Flow Restricts Flow Restricts Flow Restricts Flow <br /> 0 A/V Alarm ❑x A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes ❑x 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.) 98-3/4" 98-3/4" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 89.5% 89.5% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x 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 ❑FaIF11 ❑x 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 equipmentwas 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 facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Carrfomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br /> UN-109 www.unidocs.org 1/1 -Rev.06/14/18 <br />