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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 x❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181485 12/19/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> YRC#813 <br /> Business Site Address City ZIP Code <br /> 1535 E.Pescadero Avenue Tracy 95304 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Austin Sterling (800)339-9930 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804904 8339953 3/25/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) Of <br /> OPW 104049 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION r, n <br /> Inspection Method ❑Manufacturer Guidelines(Specify): <br /> Used: <br /> ❑x Industry Code or Engineering Standard(Specify):PEI-1200 ENVRUNMENTAL <br /> [.GENT <br /> DEPAR <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 0 <br /> TANK ID:(By tank number,stored product,etc.) Motor oil 10,000 gal Waste oil 6000 gal Soap tank 10,000 gal <br /> What is the tank inside diameter?(Inches) 92.00" 92.00" 94.00" <br /> Is the fill piping secondarily contained? 0 Yes ❑No 0 Yes ❑No Z Yes ❑No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? 0 Yes ❑No Fx1 Yes ❑No 0 Yes ❑No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply) ZRestricts Flow ZRestricts Flow 0 Restricts Flow ElRestricts Flow <br /> ❑A/V Alarm ❑AA/Alarm ❑AIV Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes Ex No ❑Yes ❑x No ❑Yes ❑x No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 82.8" 82.8" 87.42" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90% 90% 93% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes I]Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑ No(Specify in V.) ❑ No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail j ❑x Pass ❑Fail ❑x 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 Signatu;09— <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Cafifornia Environmental Reporting System,ID=Identification,UST=Underground Storage Tarts,ICC=International Code Council,AN=Audible and Visual <br /> UN-109 www.unidor-s.org 111 -Rev.06/14/18 <br />