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t <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ®36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181549 10/12/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> Lodi Muni Service Center, City of Lodi <br /> Business Site Address City ZIP Code <br /> 1331 S. Ham Lane Lodi 95240 <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 /> Eric Mol acrd 209 367-4800 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 774802 8881020 02/25/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ❑ Manufacturer Guidelines(Specify) <br /> ® Industry Code or Engineering Standard (Specify) PEI/RP1200-1 7 <br /> ❑ Engineered Method(Specify) <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages: 11 <br /> Tank ID: (By tank number, stored product,etc.) 204-10k-Gas 207-5k-Dsl 208-2k-Gas <br /> What is the tank inside diameter?(Inches) 92 92 75. <br /> Is the fill piping secondarily contained? ❑Yes ® No ®Yes ❑No ❑Yes ® No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes ® No ❑Yes ® No ❑Yes ® No ❑ Yes ❑ No <br /> Veeder Root OPW Veeder Root <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment ❑Shuts Off Flow ®Shuts Off Flow ❑Shuts Off Flow ❑ Shuts Off Flow <br /> response when activated? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ®AN Alarm ❑AN Alarm ®AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ® No ❑Yes ® No ❑Yes ® No ❑Yes ❑ No <br /> At what level in the tank is the overfill prevention 77 83 56 <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which 90 95 80 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating ®Yes ®Yes I ®Yes ❑Yes <br /> condition to respond when the substance ❑ No ❑ No [0:INo ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ® Pass ❑ Fail ® Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked"Fail"must be explained in this section. Any additional comments may also be provide &wv t °a: r..rv> <br /> tF <br /> �Arr <br /> N� l <br /> En 0j1p—oNMENTAL <br /> HEW H <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,title 23,division 3, <br /> chapter 16,section 2637.2 and all the infor ation ontained herein is accurate. <br /> UST Service Technician Si <br /> if the facility has more c onents than this form accommodates,additional copies of this page may be attached. <br /> CERS=Cafifornia Environmental Reporting System ID=Identification.UST=Underground storage tank,ICC=International Code Council,AIV=Audible and visual <br />