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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑Installation Inspection ❑x Repair Inspection ❑36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10186687 3/29/2019 Business Name(Same as Facility Name or DBA-Doing Business As) CA Gasoline _ Business Site Address City ZIP Code 2115 W. Yosemite Ave Manteca 95337 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Nicholas Poblano (916) 373-1166 Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date 617238 8360826 6/2/2019 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) Veeder-Root inao wim 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INF Inspection Method ❑Manufacturer Guidelines(Specify): t� Used: 1y� -0. 4 20119 ❑x Industry Code or Engineering Standard(Specify): PEI 1200 TAI.t�� ❑Engineered Method(Specify): PE1WTTISE Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages TANK ID:(By tank number,stored product,etc.) 2-Diesel What is the tank inside diameter?(Inches) 119.63 Is the fill piping secondarily contained? ❑Yes ❑No x❑Yes ❑No 2 Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes ❑No 2 Yes ❑No ❑Yes 2 No ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) Veeder Root What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activated? ❑ (Check all that apply.) ❑ Restricts Flow Restricts Flow [j Restricts Flow E]Restricts Flow ❑AN Alarm ❑x AN Alarm ❑AN Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ❑Yes ❑No HI Yes ❑No ❑Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 101 What is the percent capacity of the tank at which the 90 overfill prevention equipment activates? Is the overfill prevention in proper operating condition ❑Yes El Yes ❑Yes ❑Yes to respond when the substance reaches the appropriate level? ❑No(Specify in V.) [INo(Specify in V.) ElNo(Specify in V.) ElNo(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass ❑ Fail ❑x Pass ❑Fail 11 ❑ Pass ❑Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked'Fail'must be explained in this section. Any additional comments may also be provided here. Audible visual alarm was replaced and retested VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas 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 u;_rm/ i>C /`P_ . f _ _. If the facilityhas more components than this formvaccommodatees,additional copies of this page maybe attached. CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Council,AN=Audible and Visual