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19204314.5 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page I of 1) Type of Action 0 installation Inspection ❑Repair Inspection Ex 36 Month Inspection I. FACILITY INFORMATION CERS ID Dale of Overfill Prevention Equipment Inspectlon 10339507 11/27/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Arco 7049 Business Site Address city ZIP Code 800 E Kettleman Lane Lodi 95240 H. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspedlon(Print as shown on the JCC Certification.) Phone# Elodio Sanchez (925) 551-7555 Contractor I Tank Tester License# ICC CerUticagon# ICC Certification Explration Dale 220793 8887127 6/4/2020 Overfill Prevention Equipment Inspection Training and Certifications(fist applicable cerilfrcations.) Veeder Root Tech Cert#B41204 Exp. 7/5/2020 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Q Manufacturer Guidelines(Specify): Used: Tank Chart, Veeder Root,Tape Measure ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): Attach the Inspection procedures and all documentation required to determine the results. *of Attached Pages TANK to.,(By tank number,stared product,ata) 87 T1 91 T2 DSL T3 What is the tank Inside diameter?(Inches) 1001/8 993/8 1007/8 Is the fill piping secondarily contained? [J Yes ❑No El Yes ❑No [E Yes ❑No E Yes ❑No Is the vent piping secondarily contained? 0 Yes E No E Yes ❑No [z Yes E No ❑Yes ❑No Overfill Prevention Equipment Manufaclurer(s) VeederRoot VeederRW veederRoot What Is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow when activated? (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow AN Alarm ❑x AIV Alarm El AIV Alarm ❑AIV Alarm Are flow restriclors Installed on vent piping? ❑Yes I]No ❑Yes Ex No ❑Yes 0 No ❑Yes ❑No Al what level In the tank is the overfill prevention set to activate?(inches from bottom of tank.) 1001/8 993/8 1007/8 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 90 90 Is the overfill prevention In proper operating condition ❑x Yes ❑z Yes EI Yes ❑Yes to respond when the substance reaches the appropriate level? ❑No(Specify In V.) E No(Specify In V.) ❑No(Specify in V.) E No(Specify In V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑x Pass ❑Fall I ❑x Pass []Fall Q Pass ❑Fail ❑Pass ❑Fail V. COMMENTS Any items marked"Fad"must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwaspected in accordance with California Code of Regulations,Title 23, Division 3,Chapter 16,Section 2637.2 an thl Info on con fined herein is accurate. UST Service Technician Signature if the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=Calilwia Reporting Syslem.ID=klen66catia,UST=Underground d Storage Tarts,ICC=International Code Card,AIV=Audible and Visual