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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 /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> Business Name(Same as Facility Name or DBA-Doing Business As) 10/29/2018 <br /> ARCO <br /> Business Site Address City ZIP Code <br /> 6009 N. EI Dorado Street T Stockton 95207 <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 /> CHRIS BISHOP <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 949066 8216429 5/2/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> VEEDER ROOT#836744 EXP 06/19/2020, OPW#0174929 EXP 07/11/2020 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑X Manufacturer Guidelines(Specify): OPw DROP TUBE INSTALLER GUIDE AND VEEDER ROOT MAG PLUS OVER FILL TESTING PROCEDURE. <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 SOUTH 87 NORTH 91 DIESEL <br /> What is the tank inside diameter?(Inches) 120.00" 120.00" 120.00„ 120.00„ <br /> Is the fill piping secondarily contained? ❑x Yes ❑No x❑Yes ❑No Z Yes ❑No 2 Yes ❑No <br /> Is the vent piping secondarily contained? 0 Yes ❑No ❑x Yes ❑No 2 Yes ❑No 2 Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW 71 SO OPW 71 SO OPW 71SO OPW 71 SO <br /> A.V.MAG PLUS PROB A.V.MAG PLUS PROB A.V.MAG PLUS PROB A.V.MAG PLUS PROB <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑X Restricts Flow ❑x Restricts Flow ❑x Restricts Flow 0 Restricts Flow <br /> ❑X AN Alarm ❑x AN Alarm ❑x AN Alarm ❑X A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes 0 No ❑Yes ❑x No ❑Yes ❑x No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 99.75" 99.50" 98.12" 99.375" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% 95% 95% 95% <br /> Is the overfill prevention in proper operating condition 0 Yes x❑Yes x❑Yes ❑x 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 ❑x Pass ❑ Fail 11 x❑ Pass ❑Fail 11 ❑X Pass ❑ Fail ❑X 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#nd all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> I <br /> If the facility has more component tan this or accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=1 entification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />