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UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspectionx 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS IDDate <br />10169781 DEC 0 5 201 <br />of Overfill Prevention Equipment Inspection <br />10/12/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Colonial Energy # 40134 <br />Business Site Address ZIP Code <br />1434 W. Yosemite Ave. - AMM&hT 95337 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification) <br />Rey Hernandez <br />Phone # <br />(916) 373-1166 <br />Contractor I Tank Tester License # <br />617238 <br />ICC Certification # <br />8712763 <br />ICC Certification Expiration Date <br />5/8/2019 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />Phase 1 EVR - CERT # 0154742 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />❑x Manufacturer Guidelines (Specify): <br />OPW Install & Maintenance Guidelines <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK I D: (By tank number, stored product, etc.) <br />DIESEL <br />What is the tank inside diameter? (Inches) <br />Is the fill piping secondarily contained? <br />Z Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑x Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />oPw <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />® Shuts Off Flow <br />❑x Restricts Flow <br />❑ A/V Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ AN Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ A/V Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes Z No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />86.375" <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />95% <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />❑x Yes <br />❑ No (Specify in V) <br />❑ Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results ❑x Pass ❑ Fail 11 ❑ 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 />ON site for an overfill inspection test. <br />Obtained passing results <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I hereby certify thatthe 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 for"Pccommodates, addi&hal 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 <br />