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i UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page f of i) Type of Action ❑Installation Inspection ❑Repair Inspection 36 Month Inspection 1. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181399 5/2/19 Business Name(Same as Facility Name or DBA-Doing Business As) Business Site Address city ZIP Code 2375 West Grant Line Road Tracy 95377 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# John E Powers Jr. 1 760-722-9002 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 888681 8190954 4/26/2020 Overfill Prevention Equipment Inspection Training and Certifications(List applicable centifications.) Veeder root TLS-350, OPW Stage I, Emco Wheaton Stage I, Phil Tite Stage I III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ®Manufacturer Guidelines(Specify): Used: Removed drop tubes and check for correct placement ❑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 ID:(By tank number,stored product,etc.) #187-1 #2 89 #3 91 #4 Diesel What is the tank Inside diameter?(Inches) 96.00" 96.00" 96.00" 96.00" Is the fill piping secondarily contained? ®Yes ❑No H Yes ❑No ®Yes ❑No IS!Yes ❑No Is the vent piping secondarily contained? Yes ❑No ®Yes ❑No 9 Yes ❑No IN Yes ❑No Overfill Prevention Equipment Manufacturers) OPW 61SO OPW61SO OPW 61S0 What Is the overfill prevention equipment response IR Shuts Off Flow 19 Shuts Off Flow ®Shuts Off Flow $I Shuts Off Flow when activated? (Check all that apply.) ®Restricts Flow ®Restricts Flow Restricts Flow $i Restricts Flow ❑A/V Alar ❑AIV Alar ❑AIV Alarm ❑AIV Alarm Are flow restrictors installed on vent piping? ❑Yes ®No ❑Yes ®No ❑Yes ®No ❑Yes 19 No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 91.2" 91.2" 91.2" 91.2" 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 ®Yes ®Yes ®Yes H 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 I ®Pass Cl Fail 1 ®Pass ❑Fall ❑Pass ❑Fall 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 2637.2 and all the Information contained herein Is accurate. UST Service Technician Signature N the facility has more components than thf torn accommodates,additional copies of this page may be attached. CERS=Calbria EnvironrnertEl Repo"System,ID=iden56cation,UST=Underground Storage Tank,ICC=lrrnafional Code Council,A/V=Audble and Visual