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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel of 1) <br /> Type of Action Installation Inspection ❑Repair Inspection ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 5/27/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Short Stop <br /> Business Site AddressCity ZIP Code <br /> 20 W Turner Rd Lodi 95240 <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 /> Chris Adams (209) 461-6337 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1001331 A-HAZ 8230218 9/1/2022 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> EBW 1014863710 Exp 7/25/2021 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to dM126" <br /> MEJ0 <br /> ed Pages <br /> TANK ID:(By tank number,stored product,etc.) $7 <br /> What is the tank inside diameter?(Inches) 126��Is the fill piping secondarily contained? Z Yes ❑No 0 Ye ❑YesIs the vent piping secondarily contained? x❑Yes ❑No x❑YeYes ❑No <br /> Overfill Prevention Equipment Manufaclurer(s) EBW EBW <br /> What is the overfill prevention equipment response Ex Shuts Off Flow ❑x 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 /> ❑A!V Alarm ❑AN Alarm ❑AIV Alarm ❑AfV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes Q No ❑Yes E No El Yes ElNo L1 Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 95% 95% <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 ❑x Yes ❑x 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.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑Fail I Il Pass ❑Fail ❑Pass <br /> ❑ Fail El Pass El 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. _)N, AL HEALTH <br /> UST Service Technician Signature <br /> lldat-r DEPAPTMENT <br /> if the facility has more components than this form accommodates,additional copies of this page maybe attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />