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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of i ) <br /> Type of Action ❑ Installation Inspection ❑ Inspection Repair Ins <br /> P p ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID 10182335 Date of Overfill Prevention Equipment Inspection <br /> 9/7/2018 <br /> Business Name (Same as Facility Name or DBA -Doing Business As) <br /> TRACY TRUCK STOP <br /> Business Site Address City ZIP Code <br /> 3940 N TRACY BLVD TRACY CA 95304 <br /> Ila UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> David Winkler ( 209 ) 744- 0112 <br /> Contractor I Tank Tester License # ICC Certification It ICC Certification Expiration Date <br /> 08- 1739 Ex. 3/31 /2020 8883059- UT 1 /29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 104 -633 Ex 3- 14- 2020 <br /> Emco # 3207 Ex . 09-21 -2020 VR : B34975 ATG : 2/8/20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify) : <br /> Used : REMOVED DROP TUBES <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify): <br /> Attach the Inspection procedures and all documentation required to determine the results. # of Attached Pages 3 <br /> TANK ID : (By tank number, stored product, etc.) DSL - W DSL - E <br /> What is the tank inside diameter? (Inches) 128 128 <br /> Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes E No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes Z No ❑ Yes No ❑ Yes ❑ No ❑ Yes [] No <br /> Overfill Prevention Equipment Manufacturer(s ) OPW OPW <br /> 61 SO 61 SO <br /> What is the overfill prevention equipment response x❑ Shuts Off Flow Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on ventin <br /> r <br /> p p g • El Yes Q No El Yes E No ❑ Yes ❑ No El Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 116 116 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 95 <br /> Is the overfill prevention in proper operating condition FX1 Yes ® Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) j ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here, <br /> V16 CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations , Title 23 , <br /> Division 3 , Chapter 16, Section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identifcalion, UST = Underground Storage Tank, ICC = Internal" Code Council, AA/ = Audible and Visual <br />