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E <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pa Q, <br /> Type of Action © installation Inspection ❑ Repair Inspection ❑ 36 Month Inspection <br /> 1 . FACILITY INFORMATION <br /> CERS ID Date of Overfill P t q' 1.60ritlfnspection <br /> 6/4/2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Lodi 76 <br /> Business Site Address City ZIP Code <br /> 141 E Harney 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 /> Steven Jones 984 - 1537 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 768938 6205 6/21 /2021 _ <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Veeder Root TLS-350 <br /> ill . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method m Manufacturer Guidelines (Specify): PEI RP 1200 <br /> Used : <br /> ❑ Industry Code or Engineering Standard (Specify) : V <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.) Regular Premium Diesel <br /> What is the tank inside diameter? (Inches) 118 . 375 118 . 375 118 . 375 _ <br /> Is the fill piping secondarily contained ? © Yes ❑ No © Yes ❑ No © Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? © Yes ❑ No © Yes ❑ No © Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? I <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ® A/V Alarm ® A/V Alarm ® A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes X No ❑ Yes © No ❑ Yes ® No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 99 . 125 99 . 75 99 . 75 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 90 90 <br /> is the overfill prevention in proper operating condition ® Yes ® Yes ® 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 /> j 1V. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail NPass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. <br /> i I <br /> t i <br /> I <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23 , <br /> Division 3 , Chapter 16, Section 2637 .2 and all the information contained herein is accurate. <br /> UST Service Technician Signature — <br /> If the facility has more components than this form acc odates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identifickon, UST = Underground Storage Tank, ICC = Intemational Code Council, AM = Audible and Visual <br /> t <br /> I <br />