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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action 0 Installation Inspection 0 Repair Inspection 0 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10156819 9/23/19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Safeway 2600 <br /> Business Site Address City ZIP Code <br /> 1987 W. 11th St Tracy 95376 <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 /> Kristopher Bell (408)971-2445 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> F.F.#1004933708 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑Manufacturer Guidelines(Specify): <br /> Used: <br /> 0 Industry Code or Engineering Standard(Specify): PEI 1200 <br /> ❑Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages <br /> TANK ID: (By tank number,stored product, etc.) 1-Regular 2-Premium 3-Diesel <br /> What is the tank inside diameter?(Inches) 119.75" 119.75" 119.75" <br /> Is the fill piping secondarily contained? 0 Yes ❑No 0 Yes ❑ No ❑✓ Yes ❑ No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ✓❑Yes ❑No ©Yes ❑ No ❑✓ Yes ❑ No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) EBW EBW EBW <br /> Defender Defender Defender <br /> What is the overfill prevention equipment response 0 Shuts Off Flow 0 Shuts Off Flow 0 Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) ❑ ❑ ❑ <br /> Restricts Flow Restricts Flow Restricts Flow Restricts Flow <br /> ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes ❑✓ 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.) 105.5' 105.5' 105.5' <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93% 93% 93% <br /> Is the overfill prevention in proper operating condition 0 Yes 0 Yes 0 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.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 0 Pass ❑ Fail 0 Pass ❑Fail 0 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 <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=Identification,UST=Underground Storage Tank,ICC=International Code Council,AIV=Audible and Visual <br />