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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 0 36 Month inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 12/ 13/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Arco 7049 <br /> Business Site Address City ZIP Code <br /> 800 E Kettleman Lane Lodi 92540 <br /> Il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on Ute ICC Certification.) Phone # <br /> David Rouse 1 ( 925 ) 5514777 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 220793 8292530 6128/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (Ust applicable certifications.) <br /> X31 A <br /> N/A <br /> )ll. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION JAN 04 2019 <br /> Inspection Method ❑ Manufacturer Guidelines (Specify): <br /> Used: <br /> ❑Q Industry Code or Engineering Standard (Specify) Tank Chart , OPW manual for install, Tape measure <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.) T1 - Unleaded TMnleaded TMnleaded T4-Unleaded <br /> What is the tank Inside diameter? (inches) 96 96 96 96 <br /> Is the fill piping secondarily contained? 2 Yes ❑ No 21 Yes [] No [9 Yes ❑ No Q Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes S No ❑ Yes I] No ❑ Yes EINo ❑ Yes H No <br /> Overfill Prevention Equipment Manufacturer(s) opw53V OPW 53V OPW 53V OPW 53V <br /> Ball Float Ball Float Bali Float Ball Float <br /> What Is the overfill prevention equipment response ❑ Shuts OK Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts ON Flow <br /> when activated? <br /> D <br /> (Check all that apply.) Restricts Flow Q Restricts Flow Q Restricts Flow D Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping? 0 Yes ❑ No Yes ❑ No Q Yes ❑ No 0 Yes ❑ No <br /> At what level in the tank Is the overfill prevention set <br /> to activate? (inches from bottom of tank.) 81 5/8 815/8 81 5/8 81 5/8 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 95 95 95 <br /> Is the overfill prevention in proper operating condition ❑ Yes p Yes 21 Yes Q Yes <br /> to respond when the substance reaches the <br /> appropriate level? A 1 [0 No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify 1n V.) ❑ No (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass 21 Fail 19 Pass ❑ Fail D Pass ❑ Fail O 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 equipmentwas in acted in accordance with California Code of Regulations , Title 23, <br /> Division 3, Chapter 16, Section 2637.2 gpd all the Igfbrma contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components th n this form accommodates, additional copies of this page may be attached. <br /> GERS = Califomia Envkonitiental Reporting System. ID = Identification. UST = Underground Storage Tarn, ICC = International Code Cound, AN = Audible and Visual <br />