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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 10154767 Date of Overfill P eve ti ipment Inspection -1 - '�� B siness Name( ame as Facility a e or D Ding 8 siness As) }�awrence Ivermore a iona�COra�ory Bldg. 879 Be,r alSpolrres oh d -�-^ - — '%cy v5m 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION N e of U.$7;Se ce Technician Performing the Inspection(Print as shown on the ICC Certification.) 7"09-834-0792 �'rlan I norMen ContraCSLTfnk Ta tes 1i #724513 !CC Certificat04962-UT ICC Certificatior}3E> at 8��te Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) U EMCO Wheaton #3253 Exp. 11-16-2020 OPW#104777 Exp. 3-14-2020 Veeder Root Cert#A31562 Exp. 6-7-2019 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ®Manufacturer Guidelines(Specify): ^- Used: Q ®Industry Code or Engineering Standard(Specify): HEI 1200 ❑Engineered Method(Specify): Attach the inspection procedures and all documentation required to determine the results. g' R t�pU TANK ID: (By tank number.stored product,etc.) Uiesel Unleaaecl What is the tank inside diameter?(Inches) 96.011 127.b" Is the fill piping secondarily contained? ❑Yes 12 No ❑Yes ®No ❑Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ®No ❑Yes ❑No El Yes ❑No Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment response R 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 ®AN 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 set85.0�� 118.011 to activate?(Inches from bottom of tank.) What is the percent capacity of the tank at which the 93.5% 96.5% overfill prevention equipment activates? Is the overfill prevention in proper operating condition ®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 ®Pass []Fail ❑Pass ® Fail 1 ❑Pass ❑Fail ❑Pass ❑Fail V. COMMENTS Any items marked'Fail"must be explained in this section. Any additional comments may also be provided here. The Gilbarco audible visual alarm sits above the door on outside of main building facing both tanks. Gilbarco alarms are set at 90% and 95%of eadh tanks capacity. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas inspected in accordancewith 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 _ l It the facility has more components than this form accommodates,additional copies of Vilrpage may be attached. CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank ICC=International Code Council,AN=Audible and Visual UN-109 www.unidocs.org 111-Rev.06114118