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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10182131 12/ 13/2018 Business Name (Same as Facility Name or DBA-Doing Business As) Pilot Flying J 168 Ripon Business Site Address City ZIP Code 1501 N . Jack Tone Rd . Ripon 95366 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Jose Ochoa ( 888 ) 972 - 7581 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 804431 8004551 - UT 12/27/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW Cert # 100826 Expiration Date : 1 - 19-2020 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method p Manufacturer Guidelines (specify): Used : Used tank chart to find 95 % . Inspected Flapper valve at 95 % ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 6 TANK ID : (By tank number, storedproduct, etc.) Tank- 8 Bio-Diesel Tank-4 87 Tank- 5 91 What is the tank inside diameter? (Inches) 1183/8 If 1173/4 If 1173/4 11 Is the fill piping secondarily contained ? ❑x Yes ❑ No ❑ Yes ❑x No ❑ Yes ❑x No 171 Yes ❑ No Is the vent piping secondarily contained? ❑x Yes ❑ No ❑ Yes Z No ❑ Yes E] No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW Flapper Phil-Tite Flapper Phil-rite Flapper 95% 95% 95% What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes 0 No El Yes N No El Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 1093/4 110 108 " What is the percent capacity of the tank at which the overfill prevention equipment activates? 97 % 96 . 74 % 96 . 76 % 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.) ❑x No (Specify in V.) El No (Specify in V) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass ❑x Fail ❑ Pass 0 Fail ❑ Pass Q Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked `Fail" must be explained in this section . Any additional comments may also be provided here. Tank #8 Bio- Diesel flapper is set at 97 % , Tank#4 87 flapper is set at 96 . 74 % and Tank#5 91flapper is set at 96 . 76 % . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION 1 hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, Title '23, Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate . UST Service Technician Signature 9 If the facility has more components than 1hisform accommodates, additional copies of this page maybe attached. o� CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual