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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 ❑X 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10063345 1/25/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> FAST LANE GAS TEST FORM 2 of 2 <br /> Business Site Address City ZIP Code <br /> 116 ROTH RD LATHROP 95330 <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 /> Felix Ramirez (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1740 Ex. 03/31/2020 8883072-UT 11/9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- FF- EBW, Phil-Tite &EVR Phase 1 1009883708 EX 11-29-20 OPW 104-634 Ex 3-14-2020 <br /> Emco 3147 Ex. 11-16-20 VR: B34976 ATG: 7/7/20 Incon 1009883708 Ex 11-30-20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: ATG VR <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 6 <br /> TANK ID:(By tank number,stored product,etc.) DIESEL DIESEL 2 <br /> What is the tank inside diameter?(Inches) 119.75 119.75 <br /> Is the fill piping secondarily contained? 0 Yes ❑ No p Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? 0 Yes ❑ No 0 Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) VEEDER VEEDER <br /> ROOT ROOT <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑ Restricts Flow <br /> ❑Q A/V Alarm 0 A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes E No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 100 100 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90% 90% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V) ❑No(Specify in V.) ❑No(Specify in V) ❑ No(Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑Q Pass ❑Fail x❑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 /> VI. 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, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature �r�tIf the facility has more components than this form accommodates,additional 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 />