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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1'at 1) <br /> Type of Action ®Installation Inspection ❑Repair Inspection ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date R Overfill Prevention Equipment Inspection <br /> 10339507 3/28/19 <br /> Business Name(Same as Fadlity Name or DBA-Doing Business As) <br /> BP/Arco #7049 <br /> Business Site Address City ZIP Code <br /> 800 East Kettleman 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 /> Pavel Kirchio l0 916-417-2484 <br /> Con¢a�tgr1 jsnk Tester License# ICC Certification# ICC Certification Expiration Date <br /> 11 00//yy 8206719 6/12/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FFS #1012393708 exp 8/20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ®Manufacturer Guidelines(Specify): <br /> Used, a F-ea�+kJ,;4 Fvc(tr. FS-0 PV �Nslada.<<oN MANUA(_ <br /> W PA-9 S/o ❑Industry Code or Engineering Standard(Specify): <br /> o e F3c7rt� <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 produc(etc.) rYes [l <br /> T-2 - T-4 <br /> What is the tank Inside diameter?(inches) 9z t <br /> Is the fill piping secondarily contained? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes <br /> ❑No ❑Yes ❑No El Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment response g]Shuts Off Flow ®Shuts Off Flow 91 Shuts Off Flow <br /> when activated? ®Shuts Off Flow <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑A/V Alarm ❑A/V Alarm ❑AIV Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ®No ❑Yes ®No ❑Yes gJ No ❑Yes <br /> At what level in the tank is the overfill prevention set 79 25 79 25 <br /> to activate. (Inches from bottom oltank) 79.25 79.25 <br /> What is the percent capacity of the tank at which the 95 95 95 95 <br /> overfill prevention equipment activates? <br /> Is the overfill prevention In proper operating condition N Yes [9Yes M Yes IM <br /> Yes <br /> to respond when the substance reaches the <br /> appropriate level? I ❑No(Specify in V.) ❑No(Specify In V.) ❑No(Specify in V.) ❑No(Spedty in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ®Pass ❑Fail 9)Pass ❑Fail 1 ®Pass ❑Fall IN 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 /> RF071 `, i <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby cetffly that the overfill preventlon puipment was Inspected In accordance wnh Cammla Code of Regulations,TMe 23, <br /> Division 3,Chapter 1e,tBedbn 2637.2 and p1lt1p inforrnatlon contained herein Is accurate, <br /> usT service Technician Signature ENVIRONMENTAL N E%�LT ' <br /> I#t9te tbdit has ntoro componanb 1tMn this torm erxom copies of thio peps may be aff shed. <br /> C IS=Csftdrtie E11VYo■1MK+a1 R4rrat0 9yeem.D`Idrt0oelion 9lorape Tank CC•k jw.W and Code Cor+rJ,AM a Auftle a d Viair <br />