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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type ofActlon M Installation Inspection ❑ Repair Inspection ❑ 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181419 04/09/2019 Business Name (Same as Facility Name or DBA-Doing Business As.) San Joaquin County Sheriffs Operations Ctr #1 Business Site Address CityZIP Code 7000 N Michael Canils Blvd French Camp 95231 Il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # M Eric Mol card 209 367 - 4800 E Contractorrrank Tester License # ICC Certification # ICC Certification Expiration Date 774802 18881020 02/25/2021 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used : ❑ Manufacturer Guidelines (Specify) _ ® Industry Code or Engineering Standard (Specify) PEURPA 200- 17 ❑ 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.) 3701 /87/25k 3702/DsU6k off What Is the tank inside diameter? (Inches) / V t f q Is the fill piping secondarily contained? ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ❑ No OPW OPW Overfill Prevention Equipment Manufacturers) 71 SO rEIAfVAlarm What Is the overfill prevention equipment 0 Shuts Off Flow ts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow response when activated? ❑ Restricts Flow tricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑ / / 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 1 l set to activate? (Inches from bottom of tank.) What Is the percent capacity of the tank at which G L , CS j 9 the overfill prevention equipment activates? 1 �1 6 a G 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 to section V.) (Specify In section V.) (Specify In section V.) (Specify in section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fall I ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS All 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 Califomia Code of Regulations, title 23, division 3, chapter 18, section 2837.2 and all the Information con ' ed herein Is accurate. UST Service Technician Signature ff the facility has more components theifthis form accommodates, additional copies of this page may be attached. CERS = Cal*rniaEN xdmnmentaliRexwftSysbenn, W = ldendfio<tion, IAT = UndaMutudedorWetank, ICC = lntenstiDrW Code Council, AIV = AudIbiexndviimW