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UNDER9ROUND STORAGE TANK <br /> OVERFILL PREVENTION Q..IFMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection ❑Repair Inspection 0 36 Month Inspection <br /> I. FACINQY IINBOAftTION <br /> of Overfill <br /> CERS ID Tte Prevention Equipment Inspection <br /> 10180623 8/24/2018 <br /> Business Name(Same as FacilityName orDBA-DoingBuENV49UNMENTAiL 'I 'IL-ML-1 W <br /> Countryside Liquor& Gas nEPARTMENT <br /> Business Site Address City ZIP Code <br /> 14971 N Highway 88 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 /> David Winkler (209) 744-0112 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2020 <br /> Emco #3207 Ex. 09-21-2020 VR: B34975 ATG: 2/8/20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: Removed Drop Tubes - Emco 1100 Method <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.) 87 OCT 91 OCT DSL <br /> What is the tank inside diameter?(Inches) 114 114 114 <br /> Is the fill piping secondarily contained? ❑Yes ❑x No ❑Yes 0 No ❑Yes 0 No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes 0 No ❑Yes Nx No ❑Yes ❑x No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW EMCO <br /> 61-SO 61-SO 1100 <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑x Restricts Flow Z Restricts Flow Z Restricts Flow ❑Restricts Flow <br /> ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes Nx No ❑Yes ❑x No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 101 96.5 86.5 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 92% 91% 81% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Z Pass ❑ Fail ❑x Pass ❑Fail x❑Pass ❑ Fail ❑Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked"Fail'must be explained in this section. Any additional comments may also be provided here. <br /> A. 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, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature V <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual <br />