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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 1936 Month Inspection I. FACILITY INFORMATION CERS ID 10154767 q Date of Overfill P,�WY6iYST6pment Inspection BLsawre"nce (Livermore IVaiIonal Laboratory AS) Bldg . 879 �� 8T996b Wbor�al Hollow Road Iracy 95ft ��nn t(�7 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION NtS(l onf I Service r ice Technician Performing the Inspection (Print as shown on the /CC Certification.) Phone 09-834-0792 L , - L '°�� C Cert�catio Date 513 � 820Contrat/ TAnXT to� #724ICC Cerfifca Overfill Prevention Equipment Inspection Training and Certifications (List applicable cerifficaSons.) EMCO Wheaton #3253 Exp. 11 - 16-2020 OPW #104777 Exp. 3- 14-2020 Veeder Root Cert #A31562 Exp. 6-7-2019 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ® Manufacturer Guidelines (Specify): Used: ® Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages j TANK ID: (By tank number, stored product, etc.) less n ea e What is the tank inside diameter? (inches) 960011 Is the fill piping secondarily contained? ❑ Yes 10 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) 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 ® AtV Alarm ® AA1 Alarm ❑ AIV Alarm ❑ A/V 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 set 8 j Orr 107 .5" to activate? (inches from bottom of tank.) What is the percent capacity of the tank at which the 90% 90% 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 /n V.) ❑ No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass ❑ 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 the Gilbarco audible / visual alarm and annunciator. The Gilbarco audible visual alarm sits above the door on outside of main building facing bAtanks. Gilbarco alarms are set at 90% and 95% of each tanks capacity. Demonstrated for SJEHD . EOr ss 7 r tP 11 P Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INS POTION 1 hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code'diVIkeduiakio §, Title 23, Division 3 , Chapter 16, Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature ENVIRONMENTAL 114 P r j If the facility has more components an this form accommodates, additional copies of this page may be attached i\, r CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual UN409 www.unidoes.org 111 - Rev. 06114118