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!f the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council, <br />UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page I of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection n 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Overfill Prevention Equipment Inspection <br />10182249 <br />11/9/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />VALLEY PACIFIC FRESNO AVE CARDLOCK <br />Business Site Address <br />City <br />ZIP Code <br />1524 FRESNO AVE <br />STOCKTON <br />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.) <br />Phone # <br />Garrett Warren <br />(916) 991 -1 100 <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />CSLB#803616 <br />8185019 <br />10/2/2019 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />" <br />Veeder-Root 842126 exp. 1-23-2019 OPW EVR 101018 exp. 6-9-2019 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMAT N <br />Inspection Method <br />❑x Manufacturer Guidelines (Specify): eLU I U, <br />Used: <br />Manufacture's IOMs <br />Q Industry Code or Engineering Standard (Specify): Industry Standard (See Faftl�N8 I N M E NTAL 11L <br />❑ Engineered Method (Specify): °p Fi 1 sdi d i <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages 8 <br />TANK ID: (By tank number, stored product, etc.) <br />T1: Diesel <br />What is the tank inside diameter? (Inches) <br />128" <br />Is the fill piping secondarily contained? <br />❑ Yes ❑x No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes N No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW 61SO <br />What is the overfill prevention equipment response <br />❑x Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />when activated? <br />(Check all that apply.) <br />❑x Restricts Flow <br />❑ Restricts Flow <br />❑ Restricts Flow <br />❑ Restricts Flow <br />❑ AIV Alarm <br />❑ A/V Alarm <br />❑ A/V Alarm <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />x❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />120 <br />What is the percent capacity of the tank at which the <br />95% <br />overfill prevention equipment activates? <br />Is the overfill prevention in proper operating condition <br />❑x Yes <br />❑ Yes <br />❑ Yes <br />❑ Yes <br />to respond when the substance reaches the <br />appropriate level? <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />I] Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />'[:]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 />Tank is equipped with a ball float. Passed. <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 />AIV =Audible and Usual <br />