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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 1 /3/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Colonial Energy Business Site Address City ZIP Code 192 Lathrop Road lathrop 195330 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Anthony Reyes (916 ) 373- 1166 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8293772 9/ 16/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW UST Phase 1 EVR Tech#103920 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : OPW Install & Maintenance Guidelines ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 Master 87 Slave 91 Gasoline Diesel What is the tank inside diameter? (Inches) 1 13 . 75 113 . 75 113 . 75 110 . 75 Is the fill piping secondarily contained? ❑x Yes ❑ No ❑x Yes ❑ No R Yes ❑ No ❑x Yes [I No Is the vent piping secondarily contained? ❑ Yes [j] No ❑ Yes E] No ❑ Yes x❑ No ❑ Yes [j] No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW OPW What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow when activated? (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AIV Alarm ❑ AN Alarm Are flow restrictors Installed on vent piping? ❑ Yes ❑x No ❑ Yes ❑Q No ❑ Yes ❑x No ❑ Yes ❑x No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 99 . 75 102 . 125 99 . 875 97 . 625 What is the percent capacity of the tank at which the overfill prevention equipment activates? 92 % 94% 92 % 920%lo Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑x Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results r ❑x Pass ❑ Fail ❑x Pass E] Fail ❑x Pass ElFail 21 Pass El Fail V. COMMENTS Any items marked `Fail' must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , Title 23, Division 3 , Chapter 16, Section 2637.2 and all the information contained herein is accurate . UST Service Technician Signature -- ;, If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl, AN = Audible and Visual l.�