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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Foff ❑ Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection 1. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10151579 2/8/2019 Business Name(Same as Facilily Name or DBA-Doing Business As) Tracy USD Service Center Business Site Address City ZIP Code 1975 W. Lowell Ave Tracy 95376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Andrew Bagley 1 (209) 367-4800 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 774802 8012449 12/24/2020 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certfRcations.) �� OPW. Emco-Wheaton � ._. ,, CRV5D Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑Manufacturer Guidelines(Specify): Used: ❑x Industry Code or Engineering Standard(Specify):PEI/RP 1200-17 ENVIRONMENTAL HEALTH ❑Engineered Method(Specify): DEPARTMENT Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages TANK ID:(By tank number,stored product,etc.) 252102/87/1 OK What is the tank inside diameter?(Inches) Cis r Is the fill piping secondarily contained? E Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? 0 Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) 0 1°W What is the overfill prevention equipment response ❑x Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activated? (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑AN Alarm ❑AIV Alarm ❑A/V Alarm ❑A/V Alarm Are flow restrictors Installed on vent piping? ❑Yes ❑x No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 8511 What is the percent capacity of the tank at which the overfill prevention equipment activates? 93.6% Is the overfill prevention in proper operating condition ❑x Yes ❑Yes ❑Yes ❑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 [xl Pess ❑Fail I []Pass ❑Fail I ❑Pass ❑Fail ❑Pa.ss ❑Fill V. COMMENTS Any items marked Fail"must be explained in this section. Any additional comments may also be provided here. This is a re-inspection.The valve was originally inspected on 10/1212018, however, the valve/tube was rusted and could not be removed for inpection and was subsequently noted as a"FAIL".A re-attempt to remove the valve for inspection and testing on 02/08/2019 was successful.The valve will shut-off flow at 93.6%of tank capacity and is considered a" PASS". 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 th9onformation contained herein is accurate. UST Service Technician Signature "i If the facility has more components than this forrdoccomrqbdates,add !es of this page may be attached. CERS=Caf(orrra Environmental Reporting System,ID=Identification,UST=Underground SbmW Tank,ICC=InWnational Code Council,AN=Audible and Visual