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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Inspection El 36 Month Inspection Type of Action ❑ Installation Inspection ElRe air P Ins P I . FACILITY INFORMATION Date of Overfill Prevention Equipment Inspection CERS ID 6/26/2019 Business Name (Same as Facility Name or DBA Doing Business As) Vanco Truck and Auto Plaza ZIP Code Business Site Address City 1033 W Charter Way Stockton 95206 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone(209) 461 -6337 Contractor / Tank Tester License # ICC Certification # ICC Certification 1Expiratiion Date Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (specify): Used : 0 Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): # of Attached Pages Attach the inspection procedures and all documentation required to determine the results, TANK ID : (By tank number, stored product, etc.) Diesel S What is the tank inside diameter? (Inches) 119 . 5 Is the fill piping secondarily contained ? EI Yes El No El Yes [I No El Yes El No El Yes [I No Is the vent piping secondarily contained? ❑ Yes No El Yes [I No El Yes El No ❑ Yes El No Overfill Prevention Equipment Manufacturers) Overfill Alarm V/R What is the overfill prevention equipment response El Shuts Off Flow El Shuts Off Flow [I Shuts Off Flow Shuts Off Flow when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) 0 All Alarm ❑ AIV Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? Is the overfill prevention in proper operating condition ❑x Yes ❑ Yes El es ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) We SUMMARY OF INSPECTION RESULTS all Fail Pass ❑ Fail Overfill Prevention Inspection Results Pass ❑ Fall E] pass ❑ Pass Fa ❑ Fail ❑ ❑ .lMl Ilia 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 equipmentwas inspected in accordance with California Code of Regulations , Title 23 , Division 3 , Chapter 16 , Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Ceifomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual