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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 ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181313 11/21/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> LODI FOOD & LIQUOR <br /> Business Site Address City ZIP Code <br /> 1225 W. LOCKEFORD STREET 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 /> Zane Nimmo (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 04-1676 Ex.03/31/2019 8883064-UT 6/1/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW, Phil-Tite &EVR Phase 1 10009843708 Ex 11-16-18 OPW 104-632 Ex 3-14-2020 <br /> Emco 3206 Ex. 9/21/2020 VR:A28446 ATG: 9/28/19 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: O P W PHASE I TESTING &SITE SPECIFIC TANK CHARTS <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 4 <br /> TANK ID:(By tank number,stored product,etc.) 1 - 87 OCT 2 - 91 OCT 3 - DIESEL <br /> What is the tank inside diameter?(Inches) 95.5 95.5 95.5 <br /> Is the fill piping secondarily contained? ❑Yes [j]No ❑Yes 0 No ❑Yes ❑x No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? 0 Yes ❑No 2 Yes ❑No 0 Yes ❑No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) opw oPw opw <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? ❑x Restricts Flow Restricts Flow ❑x Restricts Flow ❑Restricts Flow <br /> (Check all that apply.) <br /> ❑AA/Alarm ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes Z No ❑Yes 2 No ❑Yes 0 No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 8911 8911 84.5" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 96.7% 96.7% 93.2% <br /> Is the overfill prevention in proper operating condition ❑Yes ❑Yes 9e ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? Z No(Specify in V.) 0 No(Specify in V.) ❑No(Specify in V.) ❑ No(Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass ❑x Fail 0 Pass ❑x Fail ❑x 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 /> BOTH 87&91 DO NOT MEET STANDARDS REPAIR AND RETEST BY BZ. `. <br /> RE Rs ti 'i. <br /> a` .;' L <br /> 6 DQ '. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with lifornia Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurkiNVIRONMENTAL <br /> UST Service Technician Signature DEPARTMENT <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=Underground Storage Tank,ICC=International Code Council,A/V=Audible and Usual <br />