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if the facirty has rjnii:omponents than this form accommodates, additional copies of this page maybe attached. CERS =California Environmental Reporting Systeny ID = Identificatio»,USI'= Underground storage tank, ICC = Lrten�ational Code Council, A/V = Audible vid visual UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑Installation Inspection ❑Repair Inspection ®36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10182105 10/11 /2018 Business Name (Same as Facility Name or DBA -Doing Business As.) San Joaquin County Sheriffs Operations Ctr #2 (Facilities Management/Jail) Business Site Address City ZIP Code 7000 N. Michael Canlis Blvd French Camp 95231 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Eric Mol acrd 209 367 - 4800 Ext. Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date 774802 8881020 02/25/2019 Ove�ll Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW UST AST III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: ❑Manufacturer Guidelines (Specify) ® Industry Code or Engineering Standard (Specify) PEI/RP1200-17 ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages: 6 Tank ID: (By tank number, stored product, etc.) 968-20k-dsl 969-15k-dsl What is the tank inside diameter? (Inches) 119 119 Is the fill piping secondarily contained? ❑Yes ®No ❑Yes ®No ❑Yes ❑ No ❑Yes ❑ No Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ®No ❑Yes ❑ No ❑Yes ❑ No OPW OPW Overfill Prevention Equipment Manufacturers) ®Shuts Off Flow ®Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow What is the overfill prevention equipment response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow (Check all that apply.) ❑ AN Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑Yes ®No ❑Yes ®No ❑Yes ❑ No ❑Yes ❑ No At what level in the tank is the overfill prevention 106 106 set to activate? (Inches from bottom of tank.) What is the percent capacity of the tank at which 95 94 the overfill prevention equipment activates? Is the overfill prevention in proper operating ®Yes ®Yes ❑Yes ❑Yes condition to respond when the substance ❑ No ❑ No ❑ No ❑ No reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ®Pass ❑ Fail ®Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail V. COMMENTS All items marked "Fail" must be explained in this section. Any additional comments may also be provides! ��re� ; 3 ; f ,y � `� �� { 4i ;2 � -� 4 ,^ v n� ... `.I( )( ._ „ sr, 3 �� ,� �•��u� ��.�"; ��_i_ ��° � ad �k �� ��..-� . tit F „ -.e � ) � � f �i S � � .. 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 t i formation contained herein is accurate. UST Service Technicia igrr" a.--� if the facirty has rjnii:omponents than this form accommodates, additional copies of this page maybe attached. CERS =California Environmental Reporting Systeny ID = Identificatio»,USI'= Underground storage tank, ICC = Lrten�ational Code Council, A/V = Audible vid visual