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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action Q Installation Inspection ❑ Repair Inspection ❑ 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10/29/2018 Business Name (Same as Facility Name or DBA -Doing Business As) ARCO Business Site Address 6009 N. EI Dorado Street City Stockton ZIP Code 195207 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) CHRIS BISHOP Phone # Contractor I Tank Tester License # 949066 ICC Certification # 8216429 ICC Certification Expiration Date 5/2/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) VEEDER ROOT#B36744 EXP 06/19/2020, OPW#0174929 EXP 07/11/2020 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: Q Manufacturer Guidelines (Specify): OPw DROP TUBE INSTALLER GUIDE AND VEEDER ROOT MAG PLUS OVER FILL TESTING PROCEDURE. ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID: (By tank number, stored product, etc.) 87 SOUTH 87 NORTH 91 DIESEL What is the tank inside diameter? (Inches) 120.00" 120.00" 120.00„ 120.00„ Is the fill piping secondarily contained? Z Yes ❑ No 0 Yes ❑ No Z Yes ❑ No El Yes ❑ No Is the vent piping secondarily contained? 0 Yes ❑ No Yes ❑ No I] Yes E NoYes x ❑ ❑ No Overfill Prevention Equipment Manufacturer(s) OPw 71SO OPw 71 SO OPw 71 so OPw 71 so A.V. MAG PLUS PROB A.V. MAG PLUS PROB A.V. MAG PLUS PROB A.V. MAG PLUS PROS What is the overfill prevention equipment response when activated? (Check all that apply.) E Shuts Off Flow x Restricts Flow ❑ E AN Alarm ❑ Shuts Off Flow Ex Restricts Flow Ex AN Alarm ❑ Shuts Off Flow ❑x Restricts Flow ❑x AN Alarm ❑ Shuts Off Flow ❑x Restricts Flow AN Alarm Are flow restrictors installed on vent piping? ❑ Yes I] No E Yes ❑x No ❑ Yes 0 No ❑ Yes ❑>< No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 99.75" 99.50" 98.12" 99.375" What is the percent capacity of the tank at which the overfill prevention equipment activates? 95% 95% 95% 95% Is the overfill prevention in proper operating condition to respond when the substance reaches the appropriate level? 9 Yes ❑ No (Specify in V) Yes ❑ No (Specify in V.) Yes ❑ No (Specify in V.) p Yes ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results z Pass ❑ Fail I 0 Pass ❑ Fail ❑ x Pass E3 Fail r Q Pass E] Fall V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may als vidf har; Nt,,l 0 9 2018 VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 14 I hereby certify that the overfill prevention equipment was inspected in accordance with Oal fbinla Code of R6§61MW6o , ra 23. Division 3, Chapter 16, Section 2637.2 end all the information contained herein is accurate. UST Service Technician Signature J�f If the facility has more component3'than'this F ' accommodates, additional copies of this page may be attached. CERS = Cafdomia Environmental Reporting System, ID = on, UST = Undergmund Storage Tank, ICC = Intematiorlal Code Council, AtV = A dble and Visual