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UNDERGROUND STORAGE TANK <br />I rrre rac„rryrras more components rnan this roan accommodates, additional copies of this page may be attached. <br />CERS = CaNr`omia Environmental Reporting System, ID = Identification, UST= Underground Storage Tank, ICC = International Code Council, AN <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection 2136 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Overfill Prevention Equipment Inspection <br />10181231 <br />19/25/18 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Tesoro Mobil 68152 <br />Business Site Address <br />City <br />ZIP Code <br />401 W Kettleman Ln <br />Lodi <br />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.) <br />Phone # <br />Michael Briggs <br />(408) 971-0135 <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />128811 <br />8033115 <br />5/30/19 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />OPW Certification <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />® Manufacturer Guidelines (Specify): OPW 61 SO Overfill Prevention Valves Installation Instructions <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages 7 <br />TANK ID: (By tank number, stored product, etc.) <br />87 <br />91 <br />What is the tank inside diameter? (inches) <br />96 <br />Is the fill piping secondarily contained? <br />❑ Yes ©No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes ❑✓ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW 6180 <br />What is the overfill prevention equipment response <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />El Shuts Off Flow <br />when activated? <br />(Check all that apply.) <br />® Restricts Flow <br />❑ Restricts Flow <br />❑ Restricts Flow <br />❑ Restricts Flow <br />❑ AN Alarm <br />❑ AiV Alarm <br />❑ A/V Alarm <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes 0 No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />86 <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />94,91% <br />Is the overfill prevention in proper operating condition <br />® Yes <br />❑ Yes <br />❑Yes <br />❑Yes <br />to respond when the substance reaches the <br />appropriate level? <br />❑ No (Specify in V. <br />❑ No (Specify in V) <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results ® Pass ❑ Fail <br />❑ Pass ® Fail ❑ Pass ❑ Fail <br />❑ 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 />Could not test 91. Could not remove nipple. 87 Passed <br />RECEI <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TFftfN6F1h0T16N <br />I hereby certify that the o rfill prevention equipment was inspected in accordance with California Code of Regulations, Title 23, <br />Division 3, Chapter.JA Uction 2637.2 and all the information contained herein is accWa e <br />; ; <br />UST Service Technw, gnature d <br />J- <br />=Audible and Usual <br />