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UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID Date of Overfill Prevention Equipment Inspection <br />10726990 10/11/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Pilot 1017 <br />Business Site Address City ZIP Code <br />345 Roth Road Lathrop 95330 <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 />Rogelio Valencia (888) 972-7581 <br />Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br />804431 8257643 -UT 4/20/2020 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />OPW #167223 Exp.1/19/20 <br />OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method ❑x Manufacturer Guidelines (Specify): <br />Used: Step by step instructions on measurements and how to cut. <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 <br />TANK ID: (By tank number, stored product, etc.) <br />What is the tank inside <br />diameter? (Inches) <br />Is the fill piping secondarily contained? <br />Is the vent piping secondarily contained? <br />Overfill Prevention Equipment Manufactu <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />Are flow restrictors installed on vent piping? <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />T# 1 87 <br />120" <br />❑Q Yes El No <br />❑Q Yes El No <br />OPW <br />❑x Shuts Off Flow <br />❑ Restricts Flow <br />❑ AN Alarm <br />❑ Yes ❑x No <br />1061/8 <br />" <br />T#291 <br />120" <br />x❑ Yes El No <br />Yes 171 No <br />OPW <br />� Shuts Off Flow <br />❑ Restricts Flow <br />❑ W Alarm <br />❑Yes ❑x No <br />106 7/8" <br />❑Yes <br />❑ <br />No <br />❑ <br />No <br />❑Yes <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ A!V Alarm <br />❑Yes El No <br />❑Yes <br />❑ <br />No <br />❑ <br />No <br />❑Yes <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ A!V Alarm <br />❑Yes [:]No <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 ZYes 171 Yes El Yes <br />to respond when the substance reaches the <br />appropriate level? El No (Specify in V.) El No (Specify in V) El No (Specify in V.) El No (Specify in V.) <br />_ <br />Overfill Prevention Inspection Results ❑x Pass ❑Fail ❑x Pass ❑Fail F-1 <br />V_ COMMENTS <br />IV. SUMMARY OF INSPECTION RESULTS <br />Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <br />Site equipped with OPW drop tube overfill prevention set at 95% [ <br />�d0ti' <br />NVIONM <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS II��- �"3f�' -` � <br />I hereby certify that the overfill prevention equipmentwas 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, <br />UST Service Technician Signature <br />L_ G= <br />rr me racmry nas more components Man tens toren accommodates, additional copses of this page maybe attached. <br />CERS = California Environmental Reporting System, ID = Identification, UST =Underground Storage Tank, ICC = International Code Coundl, AN =Audible and Vi <br />sual <br />