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May.24, 2019 7130AM Donlee Pump Co <br />No. 2005 P. 2 <br />11 ihe•taplllty has rrtonb romponenta than this lour► accommodates, additional copies of this Page May be attached, <br />CERS = C.affarMa F-rtvtiUnrre►Nal RepaUrlg Systern. ID ;l kienfrficatian, UST = Underground Storage Tank, ICC!! <br />UNDERGROUND STORAGE TANK <br />OVi5RFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page t of f) <br />Type of Action ❑ inslailalion inspection ❑ Repair Inspection 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS W <br />10399867 <br />Lata of Ovortili Prevention Equipment Inspeolton <br />Njq� 2cI'� <br />Business Name (Soma as Facility Name orDBA-Doing Business As) <br />ER Vine Stockton <br />Business Site Address city <br />4733 S. Hwy 99 Frontage Rd. d f Stockton <br />ZIP Code <br />95215 <br />II. UNDERGROUND STORAG5 TANK SERVICE TECHNICIAN INFORMATION <br />Narne of UST Service Technician Performing the Inspection (Print as shown on the ICC Certfcation.) <br />Alex Brambila k <br />Phone # <br />{209) 837=9396 <br />Contractor i Tank Tesler t.l se 4 <br />ICC Certification # <br />8216444 <br />ICC Certification Expiration (late <br />5/112021 <br />Overfill Prevention Equipment inspection Training and Certifications (List applicable certirrcations.) <br />QPW #162925 Franklin Fueling #2499493702 <br />Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />❑x Manufacturer Ouldellnes (specify): <br />❑ Industry Code or Engineering Standard (Specify). <br />❑ Engineered Method (Specify): <br />Attach the Inspection procedures and all documentation required to determine the results. <br />of attached Pages <br />TANK IQ: (By tank nomber, storedproduct etc.) <br />f3 <br />�}, <br />G �� ll +n L <br />Whal is the lank Inside diameter? (Incites) <br />Is the sill piping secondarily contained? <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Gj Yes ❑ No <br />❑ Yes ❑ No <br />Is the van( piping secondarily contained? <br />❑ Yes ❑ No <br />C] Yes ❑ No <br />CI Yes ❑ No <br />Q Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />09W <br />cv W <br />What is the overfill prevention equipment response <br />Men activated? <br />(Check all that apply.) <br />El S}tuts Off Flow <br />estrfots 1210W <br />❑ AN Alarm <br />❑ Shuts Off Flow <br />`Restricts Flow <br />❑ AN Alarm <br />❑ Shrds Off Flow <br />eslncts Flow <br />❑ AN Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ AN Alarm <br />Are flow res(riclors installed on vent piping? <br />❑ Yes Q No <br />Cj Yes [I No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level In the tank is the overfill prevention set <br />to activate? (Inches f tiri bottom of tank.) <br />,r <br />j <br />What Is the percent capacity of the lank at WI11CJI the <br />overfill prevention equipment activates? <br />q 5 /0 <br />y <br />1 9 <br />Is the overfill prevention In proper operating condition <br />to respond when the substamrs reaches the <br />appropriate level? <br />l4tles <br />❑ No (Specify in V.) <br />'fie& <br />❑ No (Specify in V.) <br />ivyes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Spacify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Rosulls <br />as ❑ Fail <br />Pase ❑ Fall <br />T(Pass ❑Fail ❑Pass ❑ Fall <br />Vu COMMENTS <br />Any items marked Fail" must be explained in this section. Any additional comments may also he provided here. <br />ALL de"e5 wev%t vrWi'%a%j 9!5`fo sNtrjoj��. ` toys'seg1. <br />VI. CERTIFICATION BY USI' SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I hereby certify that the overfill prevention equipmentwas Inspected in accordance with California Code of Regulations, Title 233 <br />Division 3, Chapter 16, Section 2637,2 and all the Informatlon contained herein is accurate. <br />USTjrW.e Technician nature <br />Iteetna6pnat Code CaA1o1, AN= Audihto and Vislral <br />