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2020 - 06 - 23 14 : 05 TRACY TRUCK STOP 12098322312 > > P 6 / 17
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<br /> 1141 E, ENTI : E. NTINS
<br /> CiUIP. ME NSP ECT REP REPORT
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<br /> QR. FORM :
<br /> Type of Action ❑ Installation inspection ❑ Repair Inspection ® 36 Month Inspection
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<br /> 14 . F I 'llIi
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<br /> INFORMATION ;:FACILITY
<br /> CERS ID 10182335 00to of Overfill Provontion Equlpmont Inspection
<br /> 9/7/2018
<br /> Buslnose Name (Somo os Facility Nomo or DBA-Doing 8uslnoss As)
<br /> TRACY TRUCK STOP
<br /> 8uslnoss Site Address City zIP Codo
<br /> 3940 N TRACY BLVD TRACY CA 95304
<br /> 1141 'L'" " i ;:ii ! U,NDERGROUND, :STORAGE .,t. SERVICE TECHNICIAN, INFORMATION
<br /> Name of UST Service Technician Performing the inspection (Print as shown on the ICC Cerit/lcotlon.) Phone 1l
<br /> David Winkler 7 209 744- 0112
<br /> Contractor / Teink Touter Llconao It ICC Cortlficallon # ICC Cortlficatlon Expiration Dale
<br /> 08- 1739 Ex. 3/31 /2020 8883059 - UT 1 /29/2020
<br /> Overfill Prevention Equipment Inspection Training and Certifications (List oppllcoblo corllllcotlons,)
<br /> FF- EBW , Phil=Tite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 1041t,633 Ex 3- 14-2020
<br /> Emco #3207 Ex . 09.21 =2020 VR : 834975 ATG ; 2/8/20
<br /> 4 11 11 1
<br /> 111.11; 1 1 O
<br /> . .. VERFILL. PREVENTION P EQUIPMENT. INSPECT 10N ' INFORMAT, ION
<br /> Inspection Method ® Manufacturer Guldollnos (Specify) ;
<br /> Used : REMOVED DROP TUBES
<br /> ® Industry Code or Englnaering Standard (Specify) :
<br /> ❑ Engineered Method (Spoclfy);
<br /> Attach rho Inspection procodures and all doeumontatlon roqulrod to determino tho rosults. of Attached Pagan 3
<br /> TANK Ip ; (1 tank numbei stored product, etC.) DSL - W SSL - E
<br /> Whet Is the tank Inside diameter? (Inches) 129 128
<br /> Is the fill piping secondarily contained? ❑ Yes ® No Q Yes ® No Q Yos ❑ No ❑ Yos ❑ No
<br /> Is the vent piping secondarily contained? ❑ Yes E No ❑ Yes Q No ❑ Yes ❑ No Q Yes Q No
<br /> Overfill Prevention Equipment Manufacturer(s ) OPW OPW
<br /> William 61 SO 61 $0
<br /> What Is the overfill prevention oqulpment responsex' Shuts O(( Flow E Shuts Off Flow ❑ Shute Off Flow ❑ Shuts Off Flow
<br /> when activated?
<br /> (Chock All that apply.) ❑ Restricts Flow ❑ Restricts Flow Cl Restricts Flow ❑ Restricts Flow
<br /> ❑ A/V Alarm ❑ AIV Alarm ❑ AN Alarm ❑ AN Alarm
<br /> Are (low restrlctors Installed on vont piping ? Q Yes E No Q Yes No 0 YesNo
<br /> ❑ [] Yes ❑ No
<br /> At whet lovol In tho tank Is tho overfill provontion sot
<br /> to activate? (lnchos from bottom of tank,) 116 116
<br /> What Is the percent capacity of the lank at which the
<br /> overfill prevention equipment activates? 955 95
<br /> Is the overfill prevention in proper operating condition 21 Yos ® You ❑ Yos ❑ Yos
<br /> to respond when the subotanee reaches the
<br /> appropriate level? ® No (Speclty In V,) Q No (Specify In V,) Q No (Speclly In V, ) ❑ No (Specify in V,)
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<br /> ARYOF:I.NSREC
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<br /> 4N ':.RESULTS :i
<br /> . .SUM
<br /> Overfill Provonllon inspection Rosulls Pass ❑ FellM Pass Fell ❑ Pass ❑ Fall ❑ Poss ❑ Fall
<br /> a ;. , Ill .. .411 .4. . I I I I .. .. .. ..
<br /> .13 41
<br /> V:!: ; :' fCOMMENT:S :: : :
<br /> Any Items markod "Fall” must be oxplalned In this soctlon, Any additional comments moy also be provided horn.
<br /> tit " it I;VJ : . „ ICERTIFICATION . SY' UST ,SERVICE' iTECHNICIAN :; CONDUCTING 'THIS': INSP.ECTION
<br /> 1 hereby certify that tho overfill prevention equipment was Inspoctod In accordanco with California Code of Regulatlons , Title 23 ,
<br /> Division 3 , Chapter 16, Soction 2637, 2 and all the Information contained horoin is accurate.
<br /> UST Sorvlce Technician Signature
<br /> If tho facility hbs morn components than this form accommodates, additlenal coplos of this page may bo ottachod.
<br />! CERS ® California Envircnmenmi Reporting System, ID o kientirmbon, UST o Und
<br /> erground Storage Tank ICC o tntemoliond Code Council, AN ® Audible and visual
<br /> Received Time Jun , 23 , 2020 4 : 50PM No , 6046
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