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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 ® 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181019 1 11 /29/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) <br /> Tracy Market <br /> Business Site Address City ZIP Code <br /> 15 E . Grant Line Rd . Tracy , CA 95376 <br /> Il . 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 Ext, 2 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 958763 5264361 05/08/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> W Phase 1 EVR # 10090804/06/2019 <br /> Ill . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used : ® Manufacturer Guidelines (Specify) OPW X1 SO 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 ID : (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? ® Yes ❑ No ® Yes ❑ No ® Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ® No ❑ Yes ® No ❑ Yes M No <br /> OPW OPW OPW <br /> Overfill Prevention Equipment Manufacturer(s) <br /> 61S0 61S0 61S0 <br /> What is the overfill prevention equipment ® Shuts Off Flow M Shuts Off Flow M Shuts Off Flow <br /> response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes M No ❑ Yes ® No ❑ Yes ® 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 ® Yes ® Yes M Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V. ) (Specify in section V,) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results IF ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail — � <br /> V. COMMENTS <br /> All 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 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 /> `v 0rov <br /> j If the facility has more components than this fornk4ccommodates, additional copies of this page may be attached. <br /> i <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, A/V = Audible and visual <br /> I <br />