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UNDERGROUNDSTORAGETANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181485 12/19/2018 Business Name(Same as Facility Name or DBA-Doing Business As) YRC#813 Business Site Address City ZIP Code 1535 E.Pescadero Avenue Tracy 95304 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Austin Sterling (800)339-9930 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 804904 8339953 3/25/2019 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) OPW 104049 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INF :..;. 3 Inspection Method ❑Manufacturer Guidelines(Specify): Used: E E 2 8 2012 ❑x Industry Code or Engineering Standard(Specify): PEI-1200 ❑Engineered Method(Specify): ENVIRONMENTAL HEALTH Attach the inspection procedures and all documentation required to determine the results. t ®rr 0 TANK ID:(By tank number,stored product,etc.) Waste oil 4000 gal Waste oil 1000 gal Anti-freeze 6000 gal Gear oil 6000 gal What is the tank inside diameter?(Inches) 80.00" 48.00" 92.00" 92.00" Is the fill piping secondarily contained? Z Yes ❑No El Yes ❑No ❑Yes ❑No El Yes ❑No Is the vent piping secondarily contained? Z Yes ❑No 0 Yes ❑No ❑Yes ❑No El Yes ❑No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW OPW What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow 0 Shuts Off Flow when activated? (Check all that apply.) ❑Restricts Flow Z Restricts Flow EI Restricts Flow El Restricts Flow ❑AA/Alarm ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm Are flow restrictors installed on vent piping? ❑Yes 0 No Z Yes ❑No ❑Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 64" 60" 82.8" 82.8" What is the percent capacity of the tank at which the overfill prevention equipment activates? 80% 125% 90% 90% Is the overfill prevention in proper operating condition ❑x Yes ❑Yes ❑x Yes ❑x 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 Z Pass ❑Fail ❑ Pass �Fail ❑x Pass ❑Fail 7Y7❑x Pass ❑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 23, Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signatur;09— If the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=Cafifomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Cound,AN=Audible and Usual UN-109 www.unidocs.org 111 -Rev.06/14/18