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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 10154767 Date of Overfill Pee 18tigF&Tyjpment Inspection B in; Name( me as Facility a or D ing B siness As) 11 LL yy �.awrence Livermore f�aTiona�Ca�ora ory Bldg. 879 B}r�r� Weo�ral Hollow Road �acy ?5ft TWy II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION N�n e of I�T�Ser e Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone IE09-834-0792 tSflan I orn on L Contractor T n T to i n ICC Certifica ICC Certificatio a to �� `�, -{b` W#724513 WM4962-UT A_�g Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) EMCO Wheaton #3253 Exp. 11-16-2020 OPW#104777 Exp. 3-14-2020 Veeder Root Cert#A31562 Exp. 6-7-2019 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ®Manufacturer Guidelines(Specify): Used: I@ Industry Code or Engineering Standard(Specify): PEI 1200 ❑Engineered Method(Specify): Attach the Inspection procedures and all documentation required to determine the results. #of Attached Pages 1 TANK ID:(By tank number,stored product,etc.) Uiesel Unleaded What is the tank inside diameter?(Inches) 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 Overfill Prevention Equipment Manufacturer(s) 0E-VV UPW 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 ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ®AN Alarm ®AN Alarm ❑AN Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ®Yes ❑No 0 Yes ❑No ❑Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention set 85.0" 111.0" to activate?(inches from bottom of tank.) What is the percent capacity of the tank at which the 93.5% 92.5% overfill prevention equipment activates? Is the overfill prevention in proper operating condition ®Yes ®Yes ❑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 FM—Pass ❑Fail ®Pass E3 Fail ❑Pass ❑Fail ❑Pass [I Fail V. COMMENTS Any items marked"Fail"must be explained in this section. Any additional comments may also be provided here. This report reflects inspection and testing of new Unleaded valve only, Diesel inspection was completed on 4-18-19. The Gilbarco audible visual alarm sits above the door on outside of main building faci Gilbarco alarms are set at 90% and 95%of each tanks capacity. RSCE VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTIO X/E—T. �-- I hereby certify that the overfill prevention equipment was inspected in accordance with California Coda of RFegA,�ons,Title 23, Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature -_ --_ -- - ENVIRONMENTAL HE ff the facility has more components than this form accommodates,additional copies of this page may be att4 A R TM E 1N T CERS=California Envi orrnenhal Reporting System ID=Idermtiration,UST=Underground Storage Tank ICC=International Code Coun AN=Audile and Visual UN-109 www.unidoes.org 111-Rev.06/14/18