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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 /> In FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10187387 04/17/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Valero 29 <br /> Business Site Address City ZIP Code <br /> 1137 W Lathrop Rd . Manteca 95336 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Steven White 4089712445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8898679 05/ 10/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable <br /> certifications.) 1016243710 / C24135 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify) : Veeder Root <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) 120 120 120 <br /> Is the fill piping secondarily contained? 91 Yes ❑ No 9 Yes ❑ No m Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑✓ No ❑ Yes ❑✓ No ❑ Yes 0 No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) TLS 350 TLS 350 TLS 350 <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> ❑ <br /> (Check all that apply.) ❑ <br /> Restricts Flow Restricts Flow El Restricts Flow ❑ Restricts Flow <br /> ® A/V Alarm ® A/V Alarm ® A/V 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.) 98 98 98 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90% 90% 90% <br /> Is the overfill prevention in proper operating condition ® Yes ® Yes ® Yes ❑ Yes <br /> to respond when the substance reaches the <br /> [Iappropriate level? No (Specify in V.) [I No (Specify in V.) [I No (Specify in V.) [:1 No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass El 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 /> 7, r , <br /> LAj <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING HIS NS CTION <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 * 00r � /i I _x ri� r r r <br /> UST Service Technician Signature 41x ' <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 />