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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 N 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181019 1112912018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Tracy Market <br /> Business Site Address CityZIP Code <br /> 15 E. Grant Line Rd. Tracy, CA 95376 <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 /> Nik Za orov 888 500-2435 Ed.2 <br /> Contraclorfrank Tester License ' <br /> I64CC Cenification# ICC Certification Expiration Date <br /> 958763 52361 05/08/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> OPW Phase 1 EVR#100908 exp. 04/06/2019 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: N Manufacturer Guidelines(Specify)OPW X1S0 TEST INSTRUCTIONS <br /> ❑ Industry Code or Engineering Standard(Specify) <br /> ❑Engineered Method(Specify) <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages:5 <br /> Tank to:(By tank number,stored product,etc.) Regular Regular Syp. Super <br /> What is the tank inside diameter?(Inches) 95.5 95.5 95.5 <br /> Is the fill piping secondarily contained? N Yes ❑No N Yes ❑No ®Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes N No ❑Yes N No ❑Yes N No <br /> OPW OPW OPW <br /> Overfill Prevention Equipment Manufacturer(s) <br /> 61SO 61S0 61SO <br /> What is the overfill prevention equipment N Shuts Off Flow N Shuts Off Flow N Shuts Off Flow <br /> response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ❑AN Alarm ❑AN Alarn ❑AN Alarm <br /> Are Flow restrictors installed on vent piping? ❑Yes N No ❑Yes N No ❑Yes N No <br /> At what level in the tank is the overfill prevention 85.25 85.63 86.13 <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 94 95 95 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating N Yes N Yes N Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No <br /> reaches the appropriate level? 1 (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results -Pass ❑Fail 11 N Pass ❑Fail I N Pass ❑Fail <br /> V. COMMENTS <br /> All items marked"Fair'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 equipment was Inspected In accordance with California Code of Regulations,title 23,division 3, <br /> chapter 16,section 2637.2 and all the Information contained herein is accurate. <br /> UST Service.Technician Signature <br /> ro✓ <br /> If the facility has more components than this fordQccornmodates,additional copies of this page may be attached. <br /> CERS=Catifonda Endrunmental Reporting System ID=Identification,UST=Underground storage Mak,ICC=International Code Council,AN—Audible and visual <br />