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U E058 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection I] 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181547 2/9/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Pacific Bell Telephone Co . dba AT&T California Business Site Address City ZIP Code 10 E . 12th St. 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 # Gage hart (714) 560-8222 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 588098 8361014 06/ 12/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) veeder-Root TLS-XX Technician III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (Specify) : Used : ❑x Industry Code or Engineering Standard (Specify) : PEI RP1200 ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. 76f Attached Pages TANK ID : (By tank number, stored product, etc.) UE0580002 What is the tank inside diameter? (Inches) 95 . 750 Is the fill piping secondarily contained ? 0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Veeder-root What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? ❑ (Check all that apply.) Restricts Flow El Restricts Flow ❑ Restricts Flow El Restricts Flow ❑x AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank Is the overfill prevention set to activate? (Inches from bottom of tank.) 80 . 750 What is the percent capacity of the tank at which the overfillp revention equipment activates? 90% Is the overfill prevention in proper operating condition 0 Yes nEl El Yes El Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) pecifyin V) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results D Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. El Check If Action Item (s) Are Present VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 1 hereby certify that the overfill prevention equipmentwas 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 lew *Wwa If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Visual