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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 Date of Overfill Prevention Equipment q pmeM Inspection 10181579 4/17/19 Business Name(Same as Facift Name or DBA-Doing Business As.) Tracy USD-Service Center Business Site Address City ZIP Code 1975 W. Lowell Ave Tracy 195376 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Edc aard 209 367-4800 Ext. Contractor/Tank Tester License* ICC Certification t ICC Certification Expiration Date 774802 8881020 2/25/21 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: ®Manufacturer Guidelines(Speciy)OPW ®Industry Code or Engineering Standard(Specify)PEI(RP1200-17 ❑Engineered Method(Specify) Attach the inspection procedures and ad docurnentst/on required to detwmine the results. ti of Attached Pages: Tank ID:(By tank number,stored product,etc.) 252101/DSU10k What Is the tank inside diameter?(Inches) 95 Is the fill piping secondarily contained? ❑Yes ®No ❑Yes ❑No ❑Yes ❑No Cl Yes ❑No Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No OPW Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment ®Shuts Off Flow ❑Shuts Off Flow D Shuts Off Flow Cl Shuts Off Row response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow (Check a//that apply) ❑AIV Alarm ❑AIV Alarm ❑AIV Alarm ❑AIV Alarm Are flow restridors installed on vent piping? ❑Yes ®No ❑Yes ®No ❑Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention 85 set to activate?(inches from bottom of tank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 Is the overfill prevention in proper operating ®Yes ❑Yes ❑Yes ❑Yes condition to respond when the substance ❑No ❑No ❑No No reaches the appropriate level? ❑ (Specify in section V.) (Seedy in section V.) (Specify in section V.) I (Specify In section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ®Pass ❑Fail 1 ❑Pass ❑Fail 1 ❑Pass ❑Fait ❑Pass ❑Fail V. COMMENTS All items marked'Fair 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 infonnatlon co fain herein Is accurate. UST Service Technician Signature / K the fscRNy has more componertts�lran Is farm accatvrrootahss,addtdonal copies of this page may be attached. CERs=(glean;.E.* ..Wllt.p *v.4 m=idrottfimti.atW=U-JeW-wt> .Mpaeir,ICC=Inju=soaatcodkCpm,AIV-AuM*and Awat