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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑x Repair Inspection ❑ 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181557 1 /31 /2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Valley Pacific Petroleum <br /> Business Site Address City ZIP Code <br /> 1501 W Charter Way Stockton 95206 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) one # <br /> Garrett Warren <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> CSLB#803616 8185019 9/20/2021 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Veeder- Root B42126 exp . 1 -21 -21 OPW EVR 101018 exp . 6-5-21i <br /> y, <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATIO m t <br /> Inspection Method ❑ Manufacturer Guidelines (Specify): lu IJ <br /> Used : <br /> ❑x Industry Code or Engineering Standard (Specify) : RP1200 as € int €�' " ° ; 6`nl t F 'b ,a. s i ( <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.) Diesel <br /> What is the tank inside diameter? (Inches) 96 �� <br /> Is the fill piping secondarily contained ? ❑ Yes I] No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes N No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) oPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? ❑x Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply) <br /> ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes ❑ 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.) 86 . 4 " <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 % <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑ Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? 11 ❑ 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 ❑x Pass ❑ Fail I ❑ 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 <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Coundl, AN = Audible and Visual <br />