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ARRendix IX 0 180725-583 <br /> UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENTINSPE001N REPORT (Page 5 of 11 <br /> TYPE OF ACTION ❑INSTALLATION INSPECTION ❑REPAIR INSPECTION v 36 MONTH INSPECTION <br /> 1. FACILITY INFORMATION <br /> CERS ID# DATE OF INSPECTION <br /> 10181479 1 08-07-2018 <br /> BUSINESS NAME(Same as FACILITYNAME or DBA-Doing Business As.) <br /> VERIZON BUSSINESS;KINGCA <br /> BUSINESS SITE ADDRESS CITY ZIP CODE <br /> 13850 Devries RD. LODI 95242 <br /> 11. UNDERGROUND STORAGE TANK SERVICETECHNICIAN INFORMATION <br /> ME OF UST SERVICE 1 TECHNICIAN PERFORMING INSPECTION(As shown on the!CC certification.) PHONE <br /> RUBEN BECERRA _ -- - 909-784-9148 <br /> CONTRACTOR/TANK TESTER LICENSE# ICC_CERTIFICATION# ICC CERTIFICATION EXPIRATION[?ATE <br /> 703190 5302139 01-18-2019 <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION TRAINING AND CERTIFICATIONS(Lfstapp#cable certifications.) <br /> ICC-VI <br /> 111. gARFILL PRgj1gNTIQN EQUIPMENTIN§PEgTIQN INFORMATIQN <br /> INSPECTION METHOD USED: <br /> ID MANUFACTURER GUIDELINES(Specify) <br /> ❑INDUSTRY CODE OR ENGINEERING STANDARD(Specify) <br /> ENGINEERED METHOD(Specify) <br /> Atfachthein,s ction procedures and alldocumentation required to determine the results. #OF PAGES <br /> TANK I D#(By tank number,stored product,etc.) A. UST#313 B C. <br /> DATE UST SYSTEM INSTALLED(MM/DD ) 01-01-1985 <br /> TANK INSIDE DIAMETER(Inches) 50 <br /> FILL PIPING SECONDARILY CONTAINED m_YES ONO 0 YES 11 NO 0 YES ❑NO <br /> VENT PIPING SECONDARILY CONTAINED ®YES D NO ®_YES D NO 0 YES ❑NO <br /> OVERFILL PREVENTION EQUIPMENT EBW <br /> MANUFACTURER(S) Pnuemercator <br /> OVERFILL PREVENTION EQUIPMENT q.AUTOMATIC SHUTOFF o AUTOMATIC SHUTOFF ❑AUTOMATIC SHUTOFF <br /> RESPONSE WHEN ACTIVATED o RESTRICTED FLOW 0 RESTRICTED FLOW G_RESTRICTED FLOW <br /> 62heck a#that apply.) o VISUAUAUDIBLE ALARM ❑ VISUAUAUDIBLE ALARM ❑VISUAUAUDIBLE ALARM <br /> ARE FLOW RESTRICTORS IN VENT PIPING OYES ONO OYES ONO OYES C NO <br /> INSTALLED? <br /> PERCENT CAPACITY AT WHICH THE OVERFILL 95% <br /> PREVENTION EQUIPMENT IS SET TO ACTIVATE <br /> LEVEL AT WHICH THE OVERFILL PREVENTION <br /> EQUIPMENT ACTIVATES 45" <br /> Inches from bottom of tank.) <br /> OVERFILL PREVENTION EQUIPMENT IS IN ®YES ❑ YES ❑YEAS <br /> PROPER OPERATING CONDITION TO <br /> RESPOND WHEN THE SUBSTANCE STORED ❑_ ❑_ ❑NO <br /> REACHES THE APPROPRIATE LEVEL (Sogify in s on Vj (SMffy in section V.1 (SMify in sedon V. <br /> 2F INSPECTION RESULTS <br /> OVERFILL PREVENTION INSPECTION RESULTS (r_ PASS ❑_FAIL Q.PASS o_FEIL p. PASS C FAIL <br /> V. '( <br /> Any items marked"Fail"must be explained in this section. Provide any_additional comments here. <br /> CERTIFICATION OF UST VI TECHNICIAN RESPONS1 L TI THIS INSPECTION <br /> I hereby cert° at the overfill prevention equipment was inspected in accordance vAth California Code of Regulations, <br /> title 23.division3 chapter 16,section 2637.2 and all the Information contained In this report Is true and accurate. <br /> UST SERVICE TECHNICIAN SIGNATURE Digitally signed by Ruben Becerra <br /> Ruben Becerra Date:2018.08.0710:22:08-07'00' <br />