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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection M 36 Month Inspection <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181411 512119 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Business Site Address city Tracy <br /> Code <br /> 3725 Trac Blvd Trac <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> John E Powers Jr. 1 760-722-9002 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 888681 1 8190954 4/26/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Veeder root TLS-350, OPW Stage I, Emco Wheaton Stage I, Phil Tite Stage I <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method H Manufacturer Guidelines(Specify): <br /> Used: Removed drop tubes and check for correct placement <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.) #1 87-1 #2 89 #3 91 #4 Diesel <br /> What is the tank inside diameter?(Inches) 92.00" 92,00" 92.00" 92.00" <br /> Is the fill piping secondarily contained? ®Yes ❑No ®Yes ❑No N Yes ❑No I$Yes ❑No <br /> Is the vent piping secondarily contained? Yes ❑No Yes ❑No Yes ❑No N Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW 61SO OPW61SO OPW 61S0 <br /> What is the overfill prevention equipment response ®Shuts Off Flow ®Shuts Off Flow ®Shuts Off Flow E Shuts Off Flow <br /> when activated? ®Restricts Flow ®Restricts Flow Restricts Flow N Restricts Flow <br /> (Check all that apply.) <br /> ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ®No ❑Yes ®No ❑Yes ®No ❑Yes ®No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 87.4" 87.4" 87.4" 87.4" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% 95% 95% 95% <br /> Is the overfill prevention in proper operating condition I ®Yes ®Yes )SJ Yes X Yes <br /> to respond when the substance reaches the <br /> appropriate level? I []No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results I$Pass ❑Fail I H Pass ❑Fait I ®Pass ❑Fail ❑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 vAth California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than thp form accommodates,additional copies of this page may be attached. <br /> CERS=Caftnia eM ormiental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=InWnaUonal Code Cour d7,AN=Audible and Visual <br />