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OWNERS <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL_ PREVENTION EQUIPMENT INSPECTION REPORT FORM (page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection 2136 Month Inspection <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181238 7/ 15/2019 <br /> Business Name (Same as Facility Name or DBA•Doing Business As) <br /> Arco#5450 <br /> Business Site Address City ZIP Code <br /> 1617 W . Fremont Stockton 95203 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification ) Phone # <br /> David Rouse (925 ) 551 -7555 <br /> Contractor 1 Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6/28/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications ) <br /> Veeder Root Cert. B44848 Exp . 7/ 1 /2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) <br /> Used Tank Chart , Veeder Root , Tape Measure <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 lot (By tank number, stored product, etc ) T- 1 87/M T-2 87/AUX T-3 91 <br /> What is the tank inside diameter? (inches) 92 92 92 <br /> Is the fill piping secondarily contained ? ❑x Yes ❑ No [D Yes [I No Q Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes I] No ❑ Yes 9 No ❑ Yes El No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root <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. ) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (] AIV Alarm 0 AN Alarm 0 AIV Alarm ❑ AFV Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No Q Yes CE No ❑ Yes Q No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 77 1 /8 77 1 /8 77 1 /8 <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 I] Yes Yes (] Yes ❑ 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 0 Pass ❑ Fail ❑x Pass ❑ Fail 0 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THiS INSPECTION <br /> aw <br /> I hereby certify that the overfill prevention equipment was spected in accordance with California Code of Regulations , Title 23, <br /> Division 3, Chapter 16, Section 2637. and all th nfo ion contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components fan this loin► accommodates, additional copies of this page may be attached. <br /> CERS = Caiforria Ermronmental Reporting System,. ID = kfentilicalJon, UST = Underground Storage Tank, (CC = International Code Council. AIV = Audible and Visual <br />