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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 /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevent'o Fnuinmant Inspection <br /> 1 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Valero <br /> Business Site Address city ZIP Code <br /> 1210 E Hammer Ln Stockton 95210 <br /> Ila UNDERGROUND' STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Chris Adams ( 209 ) 461 -6337 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 1001331 XHAZ 8230218 4/ 17/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FFS 1014863710 Exp 7/25/2019 <br /> 1119OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> . . . . .. . . . . . .. . . . . . . .. . .. . . . . . <br /> Inspection Method ❑x Manufacturer Guidelines (Specify): <br /> Used : <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 <br /> TANK ID : (By tank number, stored product, etc.) 87 91 Diesel <br /> What is the tank inside diameter? (Inches) 127 127 127 <br /> Is the fill piping secondarily contained? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Franklin Fueling Franklin Fueling Franklin Fueling <br /> Defender Defender Defender <br /> What is the overfill prevention equipment response (NI Shuts Off Flow (] Shuts Off Flow Q Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes 2 No ❑ Yes B No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93% 93 % 93 % <br /> Is the overfill prevention in proper operating condition ❑x Yes I] Yes 91 Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? I ❑ No (Specify In V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify In V.) <br /> IV. SUMMARY OF INSPECTIOR RESUI TS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail ❑x Pass ❑ Fail R Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS`. <br /> Any items marked Fail' must be explained in this section. Any additional comments may also b V(ded here <br /> . 0210 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN. CONDUCTING THIS INSPECTION <br /> hereby certify that the overfill prevention equipment was inspected in accordance with Cali(9: trjl406tW A d0jW6i1Sj1[ti;7437 I <br /> Division 3, Chapter 16 , Section 2637.2 and all the information contained herein is accurate. A FTT N i Nj. L <br /> UST Service Technician Signature _ <br /> If 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 = Intemational Code Council, AN Audible and Visual <br />