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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10749253 3/ 13/ 19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Costco #038 Stockton <br /> Business Site Address City ZIP Code <br /> 1630 E . Hammer Ln . 77771 Stockton 95210 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Chad White 209 532 . 7320 Ext, <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Ca623541 /09 - 1747 1 8152115 12/23/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Veeder- Root ATG Tech <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used : ® Manufacturer Guidelines (Specify) Veeder Root Probe manual 577013- 814 <br /> ® Industry Code or Engineering Standard (Specify) PEI RP 1200- 12 Section 8 . 2 . 1 . 6 <br /> ❑ Engineered Method (Specify) <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages : <br /> Tank ID : (By tank number, stored product, etc.) T1 87a T2 87b T3 91 T4 Additive <br /> What is the tank inside diameter? (Inches) 120 120 120 48 <br /> Is the fill piping secondarily contained ? M Yes ❑ No ® Yes ❑ No M Yes ❑ No M 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 M AN Alarm ® AN Alarm M AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes ® No ❑ Yes M No ❑ Yes ® No ❑ Yes M No <br /> At what level in the tank is the overfill prevention 100 . 5 100 . 5 100 . 5 40 <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 ® Yes M Yes M Yes M Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑ No <br /> reaches the appropriate level ? (Specify in section V. ) (Specify in section V . ) (Specify in section V . ) (Specify in section V . ) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail <br /> V. COMMENTS <br /> All 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 , division 3, <br /> chapter 16, section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> I <br /> /f the facility has more components t4orXI053p%ccommodates, additional copies of this page may be attached, <br /> CERS = Califorrmia Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, AN = Audible and visual <br />