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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 3/28/2019 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 # Curtis Carpenter (916 ) 373- 1166 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8167865 11 /28/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Service Tech ICC . Veeder Root level 2 , 34 . 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.) 1 -87 2- Diesel 3 -91 What is the tank inside diameter? (Inches) 119 . 63 119 . 63 119 . 63 Is the fill piping secondarily contained? 2 Yes ❑ No x❑ Yes ❑ No [] Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? N Yes ❑ No 0 Yes ❑ No 2 Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) veeder Root veeder Root veeder Root What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? Z Restricts Flow Z Restricts Flow 0 Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑x A/V Alarm ❑x AN Alarm Q AN Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? R1 Yes ❑ No Z Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 101 101 101 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 90 90 Is the overfill prevention in proper operating condition ❑ Yes ❑ Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level ? 0 No (Specify in V.) 9 No (Specify in V.) El No (Specify in V) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Pass ❑ Fail J1 ❑x Pass ❑ Fail Pass ❑ Fail [:] Pass ❑ Fail V. COMMENTS Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. While testing the overfill audible/visual alarm we found the audible portion was not working properly . A service tech will return on 3-29- 19 to make repair. 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 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