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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of t ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection p 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID spection Date of Overfill Prevention Equipment In <br /> 10182335 10/3 /2018 <br /> Business Name (Same as Facility Name or DBA -Doing Business As) <br /> CD & R Tracy Truck Stop <br /> Business Site Address City ZIP Code <br /> 3940 N . Tracy Blvd . Tracy 95304 <br /> II . 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 # ICC Certification Expiration Date <br /> 0 & 1739 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 Ex . 10- 1 -20 VR : 834975 ATG : 2/8/20 <br /> Ili . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x 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 4 <br /> TANK ID : (By tank number, stored product, etc) 87 91 <br /> What is the tank inside diameter? (Inches) 128 128 <br /> Is the fill piping secondarily contained? ❑ Yes [j] No ❑ Yes 2 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes [j] No ❑ Yes Z 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 [E 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 vent piping ? ❑ Yes ❑x No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 117 117 <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 0 Yes O Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level ? I ❑ No (Specify in V.) ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Q Pass ❑ Fail ❑x Pass [:] Fall ❑ 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 /> VI . 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 7 <br /> d <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Vsual <br />