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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection lx 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of overfill Prevention Equipment inspection 10141507 9/ 13/2018 Business Name (Same as Facility Name or DBA -Doing Business As) Frontier - Manteca Business Site Address City :::59p5336 Code 430 West Center St Manteca II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) Phone # Raul Ochoa ( 714 ) 434 -9995 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 734854 J8029372 �_ 11 /13/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) EBW( FFS ) # 1011753710 Veeder Root #1334397 lilt OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify): Veeder ROOt Used : ® Industry Code or Engineering Standard (Specify) : PEI 1200 ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 8 TANK ID ; (By tank number, stored product, etc.) T1 Diesel T1 Diesel What is the tank inside diameter? (inches) 92 92 " Is the fill piping secondarily contained? El Yes ❑ No kE91 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? 0 Yes ❑ No Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) EBW Veeder Root What is the overfill prevention equipment response x❑ Shuts Off Flow rEl Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? (Check all that apply.) ❑ Restricts Flow Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ AN Alarm (] AN Alarm ❑ AiV 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 set „ to activate? (inches from bottom of tank.) 72 . 5 „ 77 What is the percent capacity of the tank at which the overfill prevention equipment activates? 78 % 90 % Is the overfill prevention in proper operating condition ® Yes ® Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) IV . SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail Q 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. Unable to remove 4 ” bung on ball float to inspect - seized on . VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify thatthe overfill prevention equipmentwas inspected in accordancewith California Code of Regulations, Title 23 , Division 3 , Chapter 16 , Section 263 2 and all the information c ntained herein is accurate . jr 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 Council, AIV = Audible and Visual UN -109 www.unidoes. org 1 /1 - Rev. 06/14/18 i