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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180975 6/ 19/2019 Business Name (Same as Facility Name or DBA-Doing Business As) TOSCO 08671 Stockton 76 Business Site Address City ZIP Code 8606 Thornton Stockton 95209 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Garrett Warren Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date CSLB#803616 8185019 10/2/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Veeder- Root 842126 exp . 1 -21 -21 OPW EVR 101018 exp . 6-5-21 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (Specify) : Used : N Industry Code or Engineering Standard (Specify) : RP1200 ❑ 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.) T1 : 91 T2 : 89 T3 : 87 What is the tank inside diameter? (Inches) 91 If 91 if 91 if Is the fill piping secondarily contained? ❑x Yes ❑ No I] Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? H Yes ❑ No El Yes ❑ No Z Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) oPW oPW oPW What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated ? ❑x Restricts Flow ❑x Restricts Flow N Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑ AIV Alarm R A/V Alarm ❑ AIV Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping ? ❑ Yes E No ❑ Yes E No ❑ Yes Rx No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 828282If 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 ❑x YesYes Z Yes El 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 ❑x Pass ❑ Fail I Z Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. 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 mor components than this form accommodates, additional copies of this page maybe attached. CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual