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19202880 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181087 8/26/2019 Business Name (Same as Facility Name or DBA -Doing Business As) Arco 2093 Business Site Address City ZIP Code 3425 Tracy Blvd . Tracy 95376 Ile UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification ) Phone # David Rouse ( 925 ) 551 -7555 Contractor I Tank Tesler License # ICC Certification # ICC Certification Expiration Date 220793 8292530 6/28/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications ) Veeder Root tech Cert #1344848 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) Used Tank Chart, Veeder Root Manual , Tape Measure ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK We (By tank number, stored product. etc ) 11 -87 TM7 TIE T4**91 What is the lank inside diameter? (Inches) 90 90 90 90 Is the fill piping secondarily contained ? El Yes ❑ No El Yes ❑ No B Yes ❑ No 2 Yes ❑ No Is the vent piping secondarily contained? ❑ Yes ❑x No ❑ Yes 21No 0 Yesx❑ No D Yes 2 No Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root Veeder Root What is the overfill prevention equipment response 0 Shuts Oft Flow ❑ Shuts Off Flow [] Shuts Ott Flow ❑ Shots Off Flow when activated? (Check all that apply,) © Restricts Flow C] Restricts Flow ❑ Restricts Flow C3Restricts Flow 0 AN AlarmxQ AN Alarm 9 AN Alarm E] AN Alarm Are flow restrictors installed on vent plping �; ❑ Yes E No ❑ Yes 0 No 2 Yes ❑ No ❑ Yes ® No At what level in the lank is the overfill prevention set to activate? (inches from bottom of tank ) 75 75 75 75 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 90 90 90 Is the overfill prevention in proper operating condition ❑x Yes ® Yes 2 Yes El 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 ❑x Pass ❑ Fail 2) Pass ee' ❑ Fail 0 Pass ❑ Fail Q Pass ❑ Fail V. COMMENTS Any items marked `Fail ' must be explained In this section Any additional comments may also be provided here 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 . 3And a e information contained herein is accurate. UST Service Technician Si re If the facility has more ponents than this form accommodates, additional copies of this page may be attached CERS = California Envirorxnental Reporting System, ID = Identification. UST = Underground Storage Tank, ICC = Intemational Code Council W = Audible and Visual I i