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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181461 2/26/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Vanco Truck and Auto Plaza <br /> Business Site Address City ZIP Code <br /> 1033 W Charter Way Stockton 95206 <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 /> Hank Moore 1 (209 ) 461 -6337 <br /> C Certification Expiration Date <br /> Contractor I Tank Tester License # ICC Certification # IC <br /> 8833245 9/25/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> 1011473708 <br /> - III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> inspection Method ❑ Manufacturer Guidelines (Specify): <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.) Racing Fuel 87 91 Diesel N <br /> What is the tank inside diameter? (Inches) 92 92 92 119 . 5 <br /> Is the fill piping secondarily contained? 0 Yes ❑ No El Yes ❑ No 0 Yes ❑ No I] Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑ No ❑ Yes I] No ❑ Yes E] No ❑ Yes (] No <br /> Overfill Prevention Equipment Manufacturer(s) Overfill Alarm overfill Alarm overfill Alarm Overfill Alarm <br /> V/R V/R V/R V/R <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.) ElRestricts Flow ElRestricts Flow EIRestricts Flow ElRestricts Flow <br /> 9 AN Alarm p AIV Alarm Z A/V Alarm Z AfV Alarm <br /> Are flow restrictors installed on vent piping? <br /> El Yes El No (] Yes [I No Yes ❑ No Yes [I No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes 0 Yes <br /> to respond when the substance reaches the <br /> appropriate level? ElNo (Specify in V.) ElNo (Specify in V.) ElNo (Specify in V.) ❑ No (Specify In V.) <br /> N. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results [� Pass ❑ Fall Pass ❑ Fail 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 /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23, <br /> Division 3, Chapter 16, Section 2637. 2 and all the Information contained herein is accurate. <br /> UST Service Technician Signature /L� 162 <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AW = Audible and Usual <br />