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UNDERGROUND STORAGE TANK If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council, AN =Audible and Vi OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181461 2/28/2019 Business Name (Same as Facility Name or DBA -Doing Business As) VANCO TRUCK AND AUTO PLAZA Test Form 2 of 2 Business Site Address City ZIP Code 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 # Zane Nimmo (209) 744-0112 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 04-1676 Ex.03/31/2019 8883064 -UT _ 6/1/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW PhikTite & EVR Phase 1 10009843708 Ex 11-29-20 OPW 104-632 Ex 3-14-2020 , Emco 3206 Ex. 11/14/2020 ATG: VR: A28446 Ex. 9/28/19 Incon # 1009843708 Ex. 11-30-20 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Zx Manufacturer Guidelines (Specify): VEEDER ROOT TLS - 350 PROBE TESTING Used: ❑ Industry Code or Engineering Standard (Specify): - ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 5 TANK ID: (By tank number, storedproduct, etc.) 4 - DSL - souk 5 -DSL - north What is the tank inside diameter? (Inches) 119.5 119.5 Is the fill piping secondarily contained? (] Yes ❑ No El Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑x Yes ❑ No EI Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) VEEDER ROOT V R What is the overfill prevention equipment response Z Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? El Restricts Flow ❑Restricts Flow ❑Restricts Flow El Restricts Flow (Check all that apply.) ❑x AIV Alarm ❑Q AIV Alarm ❑ AIV Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping? Z Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set 100.0 100.0 to activate? (Inches from bottom of tank.) What is the percent capacity of the tank at which the 90% 90% overfill prevention equipment activates? Is the overfill prevention in proper operating condition Zx Yes ❑x Yes ❑ Yes ❑ 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) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Pass El Fail 9 Pass ❑Fail ❑ Pass El Fail El Pass El 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 was inspected in accordance with California Code of Regulations, Title 233 Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature sual