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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 />1. FACILITY INFORMATION <br />CERS ID <br />10181667 <br />Date of Overfill Prevention Equipment Inspection <br />10/12/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As.) <br />San Joaquin County Parking Garage (Downtown Garage) <br />Business Site Address <br />121 S. San Joaquin St <br />City <br />Stockton <br />ZIP Code <br />95202 <br />11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) <br />Eric Mol aard <br />Phone # <br />209 367 - 4800 Ext. <br />Contractor/Tank Tester License # <br />774802 <br />ICC Certification # <br />8881020 <br />ICC Certification Expiration Date <br />02/25/2019 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />Veeder Root <br />111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method Used: ❑ Manufacturer Guidelines (Specify) <br />® Industry Code or Engineering Standard (Specify) PEI/RP1200-17 <br />❑ Engineered Method (Specify) <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages: <br />Tank ID: (By tank number, stored product, etc.) <br />504865/87/10k <br />What is the tank inside diameter? (Inches) <br />92 <br />Is the fill piping secondarily contained? <br />® Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />® Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s)What <br />Root <br />rer <br />is the overfill prevention equipment <br />response when activated? <br />(Check all that apply.) <br />uts Off Flow <br />stricts Flow <br />® A/V Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ AN Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ AN Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ AN Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes ® No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention <br />set to activate? (Inches from bottom of tank.) <br />76 <br />What is the percent capacity of the tank at which <br />the overfill prevention equipment activates? <br />90 <br />Is the overfill prevention in proper operating <br />condition to respond when the substance <br />reaches the appropriate level? <br />® Yes <br />❑ No <br />(Specify in section V.) <br />❑ Yes <br />❑ No <br />(Specify in section V.) <br />❑ Yes <br />❑ No <br />(Specify in section V.) <br />❑ Yes <br />❑ No <br />(Specify in section V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />®Pass ❑ Fail <br />I ❑ Pass ❑ Fail❑ <br />Pass ❑ Fail <br />❑ Pass ❑ Fail <br />V. ' COMMENTS <br />All items marked "Fail' must be explained in this section. Any additional comments may also be provided here. <br />Please Note: CERS updated to Tank Construction - Yes Audible/Visual Alarm and No Shut off Valve <br />fX <br />unv <br />N-W- <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING ,.. <br />1 hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regu ations, title 23, division 3, <br />chapter 16, section 2637.2 and all t inf mation contained herein is accurate. <br />UST Service Technician at <br />If the facility has m omponents thegthis form accommodates, additional copies of this page may be attached. <br />CERS = California Environmental ReWrti* System, ID = Identification, UST = Underground storage tank, ICC = International Code Counal, AN = Audible and visual <br />