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i i t i I UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection M 36 Month Inspection j i 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180641 10/ 1 /2018 I Business Name (Same as Facility Name or DBA-Doing Business As) ' Quik Stop Market # 148 Business Site Address City ZIP Code 205 W . Lockeford Lodi 95240 I II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) Phone # i Max Hines , Paul Wright Contractor 1 Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8750053 11 /9/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW 100565 Ili. OVERFILL PREVENTION EQUIPMENT INSPECTION INFO"M Inspection Method ❑x Manufacturer Guidelines (Specify) : OCT 218 Used : OPW ® N N EMMMM ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): ENVIRONMENTAL - TH Attach the inspection procedures and all documentation required to determine the results. # of Att a ge TANK ID : (By tank number, stored product, etc.) 89 87 91 What is the tank inside diameter? (inches) 89 314if 893/4 893/4 Is the fill piping secondarily contained? Yes ❑ No (] Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑x Yes ❑ No El Yes ❑ No ❑ Yes ❑ No ❑ Yes [INo Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? (Check all that apply.) 9Restricts Flow (] Restricts Flow 9 Restricts Flow ❑ Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AIV Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes [j] No ❑ Yes ❑ No At what level in the tank is the overfill prevention set 80 3/8 ° 80 3/$" 801 /4° to activate? (Inches from bottom of tank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? Is the overfill prevention in proper operating condition I] Yes R Yes N Yes ❑ Yes to respond when the substance reaches the appropriate level? El No (Specify In V.) El No (Specify in V.) [I No (Specify in V.) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑x Pass ❑ Fail I N Pass ❑ Fail Q Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fall' must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify thatthe overfill prevention equipmentwas inspected in accordancewith 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 g, / i ��yut¢� If the facilfty has more components than this form accommodates, additional copies of this page maybe attached. CERS = Caliibmia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = intemational Code Council, AN = Audible and Visual