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19204310.5 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page i of 1) <br /> Type of Action x❑Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10339507 11/27/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Arco 7049 <br /> Bushess Site Address City ZIP Code <br /> 800 E Kettleman Lane Lodi 95240 <br /> il. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Bodo Sanchez (925 551-7555 <br /> Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Dale <br /> 220793 8887127 6/4/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> OPW Tech Cert#100695 Exp. 10/24/2019 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: Tank Chart, OPW,Tape Measure <br /> ❑Industry Code or Engineering Standard(SpecNy): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation #of Attached Pages <br /> p p required to determine the results. <br /> TANK ID:(By tank number,stored product,elm) 87 T1 91 T2 DSL <br /> What Is the tank Inside diameter?(inches) 1001/8 993/8 1007/8 <br /> Is the fill piping secondarily contained? ❑>, Yes ❑No 0 Yes ❑No B Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? 0 Yes ❑No El Yes ❑No 0 Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturers) DPW ppyy DPW <br /> What is the overfill prevention equipment response JR Shuts OB Flow Q Shuts Off Flow [E Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check ail that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑AIV Alarm ❑A(V Alarm ❑AfV Alarm ❑AfV Alarm <br /> Are Now restrictors Installed on vent piping? ❑Yes 0 No ❑Yes M No ❑Yes EINo ❑Yes ❑No <br /> At what level In the tank Is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 1031/8 1041/2 1051/2 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 92.1 93.6 93.3 <br /> Is the overfill prevention In proper operating condition IE Yes ❑x Yes El 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 Q Pass ❑Fall El Pass []Fall Q 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 SERVIQE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill provention_jLquipmentwa/)fispoctpd In accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 VA4XII Upe Info tion c9flained herein Is accurate. <br /> UST Service Technician Signature <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-Unclergrarrd Storage Tank.ICC=InlernaUanal Code Card,AIV=Audible and Visual <br />