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UG010 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181541 1 /22/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Pacific Bell Telephone Co . dba AT&T California Business Site Address City ZIP Code 1812 Coley Ave . Escalon 95320 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Jarrett Flewellyn (714) 560-8222 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 588098 8028164 03-23-2019 Overfill Prevention Equippment Inspection Training and Certifications (List applicable certifications.) Gilbarco - B36959 - 07-04-2019 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (Specify) : Used : ❑x Industry Code or Engineering Standard (Specify) : PEI RP1200 ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 0001 00001 What is the tank inside diameter? (Inches) 63 . 75 ' Is the fill piping secondarily contained ? ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? Z Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Gilbarco What is the overfill prevention equipment response ❑ 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 E AN Alarm ❑ A/V Alarm ❑ AN Alarm ❑ AN 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 set to activate? (Inches from bottom of tank.) 53 . 75' What is the percent capacity of the tank at which the overfill prevention equipment activates? 90% 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 ❑Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. Check If Action Item (s) Are Present 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 the information contained herein is accurate. UST Service Technician Signature 7& If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemalional Code Council, AN = Audible and Visual