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III IN I <br /> UNDERGROfZA4E�vTANK <br /> OVERFILL PREVENTION EQUIPMENT TIP�R 'bRTrfP. RM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation inspection ❑ Repair Inspection � E 36 Month inspection <br /> 1 . FACILITY INFORMAtION - <br /> PERS 10 u IC3 Date of Overfill Prevention Equipment Inspection <br /> 101815491 ;Aa 10/ 12/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As.) ;TMS r lei <br /> Lodi Muni Service Center, City of Lodi <br /> Business Site Address ZIP Code <br /> 1331 S . Ham Lane Lodi 195240 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certiflcation) Phone # <br /> Eric Molciaard 209 367 - 4800 Exd, <br /> Contractortrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 774802 8881020 02/25/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable cert cations.) <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ❑ Manufacturer Guidelines (Specify) <br /> ® Industry Code or Engineering Standard (Specify) PEI/RP 1 200-1 7 <br /> ❑ Engineered Method (Specify) <br /> Attach the inspection procedures and off documentation required to determine the results. # of Attached Pages : 11 <br /> Tank ID : (By tank number, stored product, etc.) 204-10k-Gas 207- 5k-DSI 20$-2k-Gas <br /> What Is the tank inside diameter? (Inches) 92 92 75 . <br /> Is the fill piping secondarily contained? ❑ Yes 23 No ® Yes ❑ No ❑ Yes E No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes E No ❑ Yes E No ❑ Yes E 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.) <br /> ® AN Alarm ❑ AN Alarm E AN Alarm ❑ AN Alarm <br /> Are flow restrictors Installed on vent piping? ❑ Yes E No ❑ Yes ® No ❑ Yes E 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 E Yes E Yes E Yes ❑ Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in sectlon V. ) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results E Pass ❑ Fail E Pass ❑ Fall E Pass ❑ Fall ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked " ' " ust be explained in this section. Any additional comments may also be rou" ere. <br /> SEP 2 0 201St <br /> PERMI er t <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 talned herein Is accurate. <br /> UST Service Technician Si <br /> ff the facility has more components than this form accommodates, additional copies of this page may be attached <br /> CERS = C'aMrnia Environmental RepordwSy, Sten, iD = Identification, USI' = Unde Wmmd slorageMrdk ICC = Intmv&nat CodeCbumil, AIV = AufiMemW visual <br />