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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10456027 1 /30/2019 Business Name (Same as Facility Name or DBA-Doing Business As) TRACY 76 Business Site Address City ZIP Code 2420 W GRANT LINE TRACY 95376 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # David Winkler ( 209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil -Tite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 3 - 14-2020 Emco #3207 Ex . 11 / 16/20 ATG : VR : B34975 ATG : 2/8/20 INCON 1009853708 ExA1 /30/2020 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : REMOVED DROP TUBES ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID : (By tank number, stored product, etc.) 87 91 dsl What is the tank inside diameter? (Inches) 95 . 50 95 . 50 95 . 50 Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑X No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) oPw OPW OPW 61SO 61SO 61SO What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated ? ❑ (Check all that apply.) ❑ Restricts Flow Restricts Flow El Restricts Flow El Restricts Flow ❑ A/V Alarm ❑ AN Alarm ❑ A/V Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 851 /2 861 /2 951 /2 What is the percent capacity of the tank at which the overfill prevention equipment activates? 93 95 94 Is the overfill prevention in proper operating condition 0 Yes 0 Yes ❑x Yes ❑ 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 0 Pass ❑ Fail J1 ❑x Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here . ttool VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTINGiTI �I {N$ PECtION `- ' I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Reg ., Inions title 233 Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate . I' f ZU 19 UST Service Technician Signature V If the facility has more components than this form accommodates, additional copies of this page may be a0 CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, Algj:&M�+aTi&OF. IT