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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 [E 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181567 3/5/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> PLAZA LIQUORS #1 <br /> Business Site Address City ZIP Code <br /> 800 SOUTH 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 /> David Winkler (209) 744-0112 <br /> Contractor/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 11/29/20 OPW 104-633 Ex 3-14-2020 <br /> Emco #3207 Ex. 11/16/20 ATG: VR: B34975 ATG:2/8/20 INCON 10 08 Ex.11/3Gi2;2 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTI #TION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: REMOVED DROP TUBES f} 2019 <br /> ❑ Industry Code or Engineering Standard(Specify): `kA <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. 4 ched Pages 4 <br /> TANK ID:(By tank number,stored product,etc.) 87 91 DSL <br /> What is the tank inside diameter?(Inches) 95 95 95 <br /> Is the fill piping secondarily contained? ❑Yes ❑x No ❑Yes 0 No ❑Yes ❑X No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes 0 No ❑Yes 9 No ❑Yes ❑x No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) oPw oPw oPw <br /> 61 So 61 SO 61 SO <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes E No ❑Yes 0 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.) 85 801/2 851/2 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94.5 90 94.7 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑p Yes ❑p 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 ❑x Pass ❑Fail ❑x Pass ❑Fail I ❑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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> hereby certify thatthe 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 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=Intemational Code Council,AN=Audible and Visual <br />