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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month inspection 1. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10468777 10/10/2018 Business dame (Same as Facility Name or DBA-Doing Business As.) PaciIIc I vest Petroleum Inc. Busines$ Site Address City ZIP Code 550 W. Vai ico Rd . Tracy 195376 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of JST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Guada LiDe Sanchez 925 470 - 0803 Ext. Contracts /Tank Tester License # ICC Certification # ICC Certification Expiration Date 100546, 4 5250451 4/8/2019 Overfill P evention Equipment Inspection Training and Certifications (Ust applicable certifications.) Veed6il Root A30138 Expiresm 10/3012019 ! I III, OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: ® Manufacturer Guidelines (Specify) Veeder Root Overfill Protection Testing CES 2018=02A ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the Inspection procedures and all documentation required to determine the results. # of Attached Pages: 11 Tank ID, (By tank number, stored product etc.) T1 : 87 T2 : 91 T3 : Diesel What is the tank inside diameter? (inches) 118 118 118 Is the fill piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Veeder Root Veeder Root Veeder Root Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow response when activated? ® Restricts Flow ® Restricts Flow ® Restricts Flow ❑ Restricts Flow (Check all that apply.) ® AIV Alarm ® AN Alarm ® AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No At what level In the tank is the overfill prevention 99 98 99 set to activate? (inches from bottom of tank.) What is the percent capacity of the tank at which 90 90 90 the overfill prevention equipment activates? Is the overfill prevention in proper operating ® Yes ® Yes ® Yes ❑ Yes condition to respond when the substance ❑ No ❑ No ❑ No ❑ No reaches the appropriate level? (Specify in section V.) (Specify in sectiJV.) (Specify in section V.) (Specify in section V.) IV, SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fall V. COMMENTS All Items marked 7611" must be explained in this section. Any additional comments may also be provided here. E U a3 r N "tli C. I �� i� P�� AL i 7� k � 3im� VI, CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 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 adcommiodates, additional copies of this page may be attached. r`.FRR = i .M* rola Fmilm n wwftl Rarwfinn Rvdrwn in = kkud}Rrafinn 1 LST = I Irv1Pnwm uvl chnnvw tank W = Ar uflfaka cervi uku aal r