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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type ofAction ❑ Installation Inspection ❑ Repair Inspection 2136 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 1 /3/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Arco 2186 Business Site Address Gily ZIP Code 3212 N California Stockton 95204 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # David Rouse 1 ( 925 ) 551 -4777 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Dale 220793 8292530 6/28/2020 Overfill Prevention Equipment Inspection Training and Certifications (List apphcab/e certifications ) NIA III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (Specify) ; Used ❑x Industry Code or Engineering Standard (Specify) : Tank Charts , Veeder Root , Tape Measure ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results . # of Attached Pages TANK ID : (By tank number, storedproduct, etcj T1 - Unleaded T2-Unleaded T3 - Premium What is the tank inside diameter? (Inches) 120 120 120 Is the fill piping secondarily contained? 0 Yes ❑ No [] Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes 0 No ❑ Yes No Cl Yes I] No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts OS Flow ❑ Shuts Off Flow when activated? (Check all that apply ) ❑ Restricts Flow C1Restricts Flow [:1Restricts Flow ❑ Restricts Flow ' (] A/V Alarm Q AA/ Alarm 21 A/V Alarm ❑ AIV Alarm t Are flow restrictors installed on vent piping? ❑ Yes (] No ❑ Yes 0 No ❑ Yes [) No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (inches from bottom of tank ) 991 /2 99 991 /4 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 90 90 Is the overfill prevention In proper operating condition ❑x Yes 0 Yes (] Yes ❑ Yes to respond when the substance reaches the appropriate level? ElNo (Specify in V ) ❑ No (Specify in V ) ❑ No (Specify in V. ) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Pass ❑ Fail 0 Pass ❑ Fait Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section . Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment w s inspected in accordance with California Code of Regulations , Title 23, Division 3, Chapter 16, Section 2637.2 and al ffie lnoAation contained herein is accurate. UST Service Technician Signature If the facility has more compondiffs than this form accommodates, additional copies of this page may be attached. I' CERS = California Environmental Reporting System, ID = Iden ficaton, UST = Underground Storage Tank. ICC = International Code Co u dl. ASV = Audible and Visual �I I�Y�i