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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 0 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181557 10/26/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Valley Pacific Petroleum Services <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.) Phone# <br /> Garrett Warren 1 (916) 991-1100 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> CSLB#803616 8185019 10/2/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) : D <br /> Veeder-Root B42126 exp. 1-23-2019 OPW EVR 101018 exp. 6-9-2019 REC <br /> i <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION WOV 0a � <br /> Inspection Method N Manufacturer Guidelines(Specify): <br /> Used: Manufacture's IOMs <br /> ®Industry Code or Engineering Standard(Specify): ry ) <br /> Indust Standard see attached VERS <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 8 <br /> TANK ID: (By tank number,storedproduct,etc.) T1: Unleaded T2: Diesel <br /> What is the tank inside diameter?(Inches) 95.75" 95.75" <br /> Is the fill piping secondarily contained? 0 Yes ❑No El Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes ®No ❑Yes [E No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPw 61so Al 100 Emco <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? ❑x Restricts Flow ❑x Restricts Flow ❑Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) <br /> ❑A/V Alarm ❑AN Alarm ❑AN Alarm ❑AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑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.) 95% 95% <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 89" 89" <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑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 Z Pass ❑Fail I ❑Pass Q 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 /> Diesel failed, not able to actuate the diesel flapper.Also Not able to remove the plug from the Unleaded and Diesel sump <br /> to verify if a ball float is installed at this time. <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 her ' . ccur te. <br /> UST Service Technician Signature <br /> If the facility has more components than t a ,a itional copies of thrs page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Carnal,A/V=Audible and Usual <br />