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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Pagel of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181401 1 /30/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> VAN DE POL - LODI PACIFIC PRIDE <br /> Business Site Address City ZIP Code <br /> 351 N . BECKMAN ROAD 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 /> Zane Nimmo ( 209 ) 744- 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04- 1676 Ex . 03/31 /2019 8883064-UT 6/ 1 /2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 10009843708 Ex 11 -29-20 OPW 104-632 Ex 3- 14-2020 <br /> Emco 3206 Ex . 11 / 14/2020 ATG : VR : A28446 Ex . 9/28/ 19 Incon # 1009843708 Ex . 11 -30-20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Z Manufacturer Guidelines (Specify) : OPW <br /> Used : <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.) 4 - DIESEL 5 - DIESEL <br /> What is the tank inside diameter? (Inches) 110m5 110 . 5 <br /> Is the fill piping secondarily contained ? Z Yes ❑ No x❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes 2 No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW oPw <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply) Restricts Flow E] Restricts Flow El Restricts Flow ❑ Restricts Flow <br /> ❑ A/V Alarm ❑ AN Alarm ❑ A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes M No ❑ Yes Z No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 100 97 . 5 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 % 93 <br /> Is the overfill prevention in proper operating condition Z Yes ❑x Yes ❑ 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 MPass ElFail ❑x Pass ❑ Fail 11 <br /> [:1 Pass El Fail ❑ Pass El Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <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 , <br /> Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> - - = International Code Council A/V = Audible and Usual <br /> CERS = California Environmental Reporting System, ID - Identification, UST - Underground Storage Tank, ICC Intern , <br /> po <br />