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� i a'aaaaaaaa ONE UNDERGROUND STORAGE TANK OVERFILL, PREVENTION EQUIPMENT INSPECTION REPO , ORM (Page 1 of 1 ) Type of Action ElInstallation Inspection ElRepair Inspection El 36 Month Inspection 1. FACILITY INFORMATION Ll . CERS ID Date Overfill Pre ment Inspection 10456027 /30/2019 Business Name (Same as Facility Name or DBA-Doing Business As) TRACY 76 Cit I T953;76 de Business Site Address City 2420 W GRANT LINE ! II. UNDERGROUND STORAGE TANK SERVICE TECHNI , i At I INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Cedfflcahon ) I Phone # David Winkler (209) 744-0112 Contractor I Tank Tester License # ICC Certification # ICC jertification 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 , PhilJite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 E 3A 2020 Emco #3207 Ex. 11 /16/20 ATG: VR: B34975 ATG : 2/8/20 INC 11 9853708 Ex. 11 /30/2020 Ilia OVERFILL PREVENTION .EQUIPMENT INSPECTIC MATION inspection Method I] Manufacturer Guidelines (Specify): Used: REMOVED DROP TUBES ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): # of Attached Pages Attach the inspection procedures and all documentation required to determine the r 'ult ,! 4 TANK ID: (By tank number, stored product etc.) 87 91 ( dSi What is the tank inside diameter? (Inches) 95 . 50 95 50 95 . 50 Is the fill piping secondarily contained? ❑ Yes © No ❑ Yes No ❑ Ybs ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes EjNo ❑ Yes n No [] ' s O No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPw OPw oPw 61 SO 61 SO 61 S0 What is the overfill prevention equipment response ❑x Shuts Off Flow [] Shuts Off Flow (] 6 uts Off Flow ❑ Shuts Off Flow when activated? l (Check a!1 that apply.) ❑ Restricts Flow El Restricts Flow ❑ � strias Flow El Restricts Flow ❑ AAlarm ❑ AN Alarm ❑ Alarm ❑ AIV Alarm N Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes I] No ❑ Yps ❑ 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 g3 95 94 overfill prevention equipment activates? Is the overfill prevention in proper operating condition Yes EI Yes x s ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ o (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESU 4 S Overfill Prevention Inspection Results Q Pass ❑ Fail 0 Pass ❑ Fail Q ass ❑ Fail El Pa ❑ Fail V. COMMENTS ' I j Any items marked "Fail' must be explained in this section. Any additional comments may !so be provided here. ! i i � Vi. CERTIFICATION BY UST SERVICE TECHNICIAN CONDLJCTINO THIS INSPECTION 1 hereby certify that the overfill prevention equipment was inspected In accordance w h Coo lifornia Code of Regulations, Title 23, Division 3, Chapter 16, Section 2637.2 and all the information contained herein is aci urat UST Service Technician Signature �d ij If the facility has more components than this form accommodates, additional copies of this pag M" a D attached. 11 CERS = Caf nia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = I Council, AN = Audible and Visual I