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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection M 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10146151 05/21 / 19 Business Name (Same as Facility Name or DBA-Doing Business As.) Costco # 1091 Lodi Business Site Address City ZIP Code 2680 Reynolds Ranch Parkway Lodi 95240 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Isaac Anderson 209 532 - 7320 Ext Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date CA 623541 /09 - 1749 8146912 06/ 12/20 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Veeder- Root Level IV 1336878 OPW 100456 PhikTi e # 1022863709 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used : ® Manufacturer Guidelines (Specify) Remove Tank gauge bring fuel float to 90 % ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages : Tank ID : (By tank number, stored product, etc.) T1 87A T2 87B T3 91 T4 Additive What is the tank inside diameter? (Inches) 120 120 120 48 Is the fill piping secondarily contained ? ❑ Yes ® No ❑ Yes M No ❑ Yes M No ❑ Yes M No Is the vent piping secondarily contained ? M Yes ❑ No ® Yes ❑ No ® Yes ❑ No M Yes ❑ No Veeder- Root Veeder- Root Veeder-Root Veeder- Root Overfill Prevention Equipment Manufacturer(s ) What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow response when activated? ElRestricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) ® A/V Alarm ® A/V Alarm M AN Alarm ® AN Alarm Are flow restrictors installed on vent piping? ❑ Yes ® No ❑ Yes M No ❑ Yes ® No ❑ Yes M No At what level in the tank is the overfill prevention 101 101 101 39 set to activate? (Inches from bottom of tank.) What is the percent capacity of the tank at which 90 90 90 90 the overfill prevention equipment activates? f ® Yes ® Yes ® Yes M Yes Is the overfill prevention in proper operating condition to respond when the substance ❑ No ❑ No ❑ No ❑ No reaches the appropriate level? (Specify in section V. ) (Specify in section V . ) (Specify in section V . ) (Specify in section V. ) I' IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ® Pass ❑ Fail M Pass ❑ Fail ][::a Pass ❑ Fail ® Pass ❑ Fail V. COMMENTS All items marked "Fail' 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 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 c tained herein is accurate. UST Service Technician Signature If the facility has more component an this form accommodates, additional copies of this page may be attached. rFRS = ralifnmia Fnvimnmanfal Rannrfinn SvcfPm. in = Idanfifirafinn. I 1.97r = I Inriemrni ind efnrana tank. ICC = Infamafinnal rnda Cnunril. AN = Audihla and vies gal