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19202880 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (page i of 1 ) <br /> Typeof Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection <br /> i . FACILITY INFORMATION <br /> CERS 10 Date of Overfill Preventson Equlpmenl Inspection <br /> 10181087 8/26/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Arco 2093 <br /> Business Site Address City ZIP Code <br /> 3425 Tracy Blvd , Tracy 95376 <br /> I1 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification ) Phone # <br /> David Rouse ( 925 ) 551 -7555 <br /> Contractor / Tank. Tester License # ICC Cedification # ICC Certfficalion Expiration Dale <br /> 220793 8292530 6/28/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications ) <br /> OPW Tech Cert #0108211 <br /> ills OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method El Manufacturer Guidelines (Specify) e Measure Tank Chart , OPW Manual , Tape P <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 <br /> TANK ID : (By tank number stored product. etc ) T1 - 87 T2-87 T3-87 T4-91 <br /> What is the tank inside diameter? (inches) 90 90 90 90 <br /> Is the fill piping secondarily contained ? ❑Q Yes ❑ No El Yes ❑ No 2 Yes ❑ No ❑x Yes ❑ No <br /> Is the vent piping secondarily contained? (_j Yes 0 No ❑ Yes 9 No ❑ Yes I] No ❑ Yes 0 No <br /> Overfill Prevention Equipment Manufaclurer(S) Defender Series Defender Serres Defender Senes Defender Series <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow �jx, Shuts Off Flow 2 Shuts Off flow 21 Shuts Off Flow <br /> when activated ? <br /> El(Check all that apply,) Restricts Flow [I Restricts Flow ❑ Restricts Flow ❑ Restricts Flaw <br /> ❑ AN Alarm © AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are Oow restriclors installed on vent piping? ❑ Yes 2 No E Yes ❑ No 0 Yes ❑ No CI Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (inches from bottom of tank.) 77 78 77 77 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates ? 93 93 93 93 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑Q Yes t] Yes Q Yes <br /> f to respond when the substance reaches the <br />€ appropriate level? ❑ No (Specify it V ) ❑ No (Specify in V ) ❑ Ni (Specify iri V } ❑ No (Specify in V ) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Q Pass ❑ Faii [] Pass ❑ Fail (] Pass ❑ Fad CE 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 arid a e information contained herein is accurate. <br /> UST Service Technician Si re <br /> tfthe facility has more ponents than this form accommodates, additional copies of this page may be attached. <br /> CERS = California ErMrormenta) Reporting System, ID = Identification, UST = Underground Storage Tank. ICC = lNemationai Code Council. NV = Audible and Visual <br />