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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of i) Type of Action ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection I. FACILITY INFORMATION CERS ID 10181487 Date of Overfill Prevention Equipment Inspection 15/21/20 Business Name (Same as Facility Name or DBA-Doing Business As) Speedway 4612 Business Site Address 2448 W Kettleman Ln. City Lodi ZIP Code 95242 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Brian McPheely 1(408) Phone # 971-2445 Contractor I Tank Tester License # 485184 ICC Certification # 8822062 ICC Certification Expiration Date 11 /1 /21 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW # 104773 Franklin Fueling Site Safety # 1014303708 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: la Manufacturer Guidelines (Specify): F.F. Defender ❑ Industry Code or Engineering Standard (Specify): ENVIRONMENTAL HEALTH ❑ Engineered Method (Specify). 7EP, Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID: (By tank number, stored product, etc.) 1-87 2-91 3-Diesel What is the tank inside diameter? (Inches) 92 92 92 Is the fill piping secondarily contained? m Yes ❑ No m Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes © No ❑ Yes © No ❑ Yes ® No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Franklin Franklin Franklin Defender Defender Defender What is the overfill prevention equipment response when activated? (Check all that apply.) ® Shuts Off Flow ❑ Restricts Flow ❑ A/V Alarm {a Shuts Off Flow ❑ Restricts Flow ❑ A/V Alarm 0 Shuts Off Flow ❑ Restricts Flow ❑ A/V Alarm ❑ Shuts Off Flow ❑ Restricts Flow ❑ A/V Alarm Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes [Z No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 83.75 83.75 83.75 What is the percent capacity of the tank at which the overfill prevention equipment activates? 95.88% 95.88% 95.88% Is the overfill prevention in proper operating condition to respond when the substance reaches the appropriate level? 0 Yes ❑ No (Specify in V.) 0 Yes ❑ No (Specify in V.) ® Yes ❑ No (Specify in V.) ❑ Yes ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass 0 Fail I ❑ Pass m Fail 1 ❑ Pass m Fail ❑Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. 87, 91 and Diesel Flappers are set over 95% and Failed. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I 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 If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = kientification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual