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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 /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 1 /25/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Tesoro # 68151 <br /> Business Site Address City ZIP Code <br /> 35 N . Cherokee 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 /> Rey Hernandez 1 ( 916) 373 - 1166 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 617238 8712763 5/8/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Phase 1 EVR-CERT # 0154742 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : OPW Install & Maintenance Guidelines <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 <br /> TANK ID : (By tank number, stored product, etc.) Gasoline - 91 <br /> What is the tank inside diameter? (Inches) 95 <br /> Is the fill piping secondarily contained ? ❑ Yes ❑ No ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑ No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow x❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes ❑ No ❑ Yes E 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.) 9553 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 % <br /> Is the overfill prevention in proper operating condition ❑ Yes 0 Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? El No (Specify in V.) El (Specify in V.) ❑ No (Specify in V) ElNo (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS __ <br /> Overfill Prevention Inspection Results El Pass [:1 Fail 0 Pass ❑ Fail ❑ 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 /> 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 t n this form accomm ates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identificalion, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Usual <br />