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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of 1) Type of Action ❑Installation Inspection ❑ Inspection Repair Ins P P Z 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment inspection Business Name(Same as Facility Name or DBA-Doing Business As) 1122/2019 Arco 6080 Business Site AddressCity ZIP Code 85 E. Louise Ave Lathrop 95330 If. 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 l Tank Tester License# ICC Certification# ICC Certification Expiration Date 220793 8292530 6/28/2019 Overfill Prevention Equipment Inspection Training and Certifications(List applicable,certificalions.) N/A Iil. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑Manufacturer Guidelines(Specify) Used Industry Code or Engineering Standard(Specify)Tank Charts, Tape Measure ❑Engineered Method(Specify) Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages TANK ID:(By lank number,stored product,etc.) T1 Unleaded JA,L T1 Unleaded (B) T2 Premium T3 Diesel What is the tank inside diameter?(inches) 119.60 119.60 119.60 119.60 Is the fill piping secondarily contained? Yes ❑No 2 Yes ❑No (]Yes ❑No EI Yes ❑No Is the vent piping secondarily contained? Q Yes ❑No 0 Yes ❑No Q Yes ❑No Q Yes Q No Overfill Prevention Equipment Manufacturer(s) OPw OPW OPw OPw 71 50 7150 7150 7150 What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activated? x Restricts Flow x Restricts Flow ❑x Restricts Flow ❑x Restricts Flow (Check all that apply) ❑ ❑ ❑AN Alarm ❑AIV Alarm ❑AIV Alarm ❑ArV Alarm Are flow restrictors installed on vent piping? ❑Yes 2 No ❑Yes EINo ❑Yes ❑x No IE Yes ❑No At what level in the tank is the overfill prevention set to activate?(inches from bottom of tank) 100 1/8 1001/8 106 3/4 1061/2 What is the percent capacity of the tank at which the overfill prevention equipment activates? 95% 95% 95% 95% Is the overfill prevention in proper operating condition 0 Yes Q Yes Yesx❑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 J IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ZPass ❑Fail Q Pass ❑Fail ❑x 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 equipmentwas irispected in accordance with California Code of Regulations,Title 23, Division 3,Chapter 16,Section 2637.2 and all thejnfomwon contained herein is accurate. UST Service Technician Signature If the facility has more components dlan this form accommodates,additional copies of this page may be attached. CERS=Callomia Elnnr onimental Reporting System.10=Identification,UST=Underground Storage Tank.ICC=International Code Council,AN=Audibie and Usual