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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ®36 Month Inspection <br /> 1. FACILITY INFORMATION <br /> CERS ID 10184317 Date of Overfill Prevention Equipment Inspection <br /> 9/28/18 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> LOVE'S TRUCK PLAZA <br /> Business Site Address City ZIP Code <br /> 1553 COLONY RD RIPON,CA 195366 <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 /> DAVE WINKLER 209 744 -0112 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 8883059-UT 1-31-20 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW Phil-Tite &F.VR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2020 Emco 713207 Ex.09-21-2020 VR:B34975 ATG:2/8/20 <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: M Manufacturer Guidelines(Specify) REMOVED DROP TUBE <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: <br /> Tank ID:(By tank number,stored product,etc.) 91 <br /> What is the tank inside diameter?(Inches) 120 <br /> Is the fill piping secondarily contained? ®Yes ❑ No ❑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) OPW <br /> 6150 <br /> What is the overfill prevention equipment ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ® Restricts Flow ❑Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ® No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑ No <br /> At what level in the tank is the overfill prevention 115 <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 95 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating M Yes ❑Yes ❑fes ❑Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass [-] Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked"Fair must be explained in this section. Any additional comments may also be provided here. <br /> i <br /> EN NMENTAL 'r <br /> nFPARTMEN <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,division 3, <br /> 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 />