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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 ® 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181249 12/21 /2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> ARP Min/ Mart Mobil <br /> Business Site Address city ZIP Code <br /> 25775 S . Patterson Pass Rd . Tracy 195376 <br /> 11, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Guadalu a Sanchez (9251470 - 0803 Ext. <br /> Contractorfrank Tester License # ICC Certification # T 'cc Certification Expiration Date <br /> 1005444 15250451 4/8/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable cert/fications.) <br /> Veeder Root A30138 Expires : 1013 019 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ® Manufacturer Guidelines (Specify) Vcpder Root Overfill Protection Testing CEB 2018-02A <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: 9 <br /> Tank ID: (By tank number, stored product etc.) T1 : 87 Slave T2: 87 Master T3 : Diesel T4: 91 <br /> What is the tank Inside diameter? (inches) 89 89 89 89 <br /> Is the fill piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No <br /> Veeder Root Veeder Root Veeder Root Veeder Root <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ® AN Alarm ® AN Alarm ® AN Alarm ® AN Alarm <br /> Are flow restrictors Installed on vent piping? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> At what level in the tank is the overfill prevention 75 75 75 75 <br /> set to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 90 90 90 90 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating L <br /> ® Yes M Yes ® Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No <br /> reaches the appropriate level? y in section V.) (Specify in section V.) (Specify in section VJ (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fai! O Pass ❑ Fail ® Pass ❑ Faii ® Pass ❑ Fall <br /> V. COMMENTS <br /> All items marked Fall" must be explained in this section. Any additional comments may also be provided here. <br /> V1 . 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, division 3, <br /> 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 acconrfmodates, additio r <br /> copies of this page maybe attached. <br /> r:FR.R a ralifnm1a Fnvirnnnuwvtal Rmvuffm Rvafcvn in a Irk+nMmOinn I LST d etnraro tank ir:r: a 1nfPnvtinnal r"iP [`.rn uvdl AN a Ae vilhra ant via W <br />