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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 ❑x 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181397 1/29/18 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> EF KLUDT Test Form 1 of 2 <br /> Business Site Address City ZIP Code <br /> 1126 E PINE ST LODI 95241 <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 /> Edward Stearns (209) 744-0112 <br /> Contractor I Tank Tester License# ICC Certification# CC Certification Expiration Date <br /> 14-1760 Ex. 09/30/2020 8883080-UT---7 11/9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite &EVR Phase 1 1009893708 Ex 11/29/2020 OPW 104-635 , , y, <br /> Emco 3205 Ex. 11/16/2020 ATG:VR A31048 Ex.8/9/19 Incon 1009893708 11/3 /2 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMA 2019 <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): REMOVED AND INSPECTED <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): ENVIRONMENI AL HEA <br /> T <br /> ElEngineered Method(Specify): a— <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 5 <br /> TANK ID: (By tank number,storedproduct,etc.) T-2 DYED DIFd 3-DYED DIEM 5 110 OCT <br /> What is the tank inside diameter?(Inches) 96 96 75.50 <br /> Is the fill piping secondarily contained? ❑Yes 0 No ❑Yes [H]No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes 0 No ❑Yes El No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑AIV Alarm ❑AN Alarm ❑AIV Alarm ❑AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes 0 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.) 86 86 68 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94 94 95 <br /> Is the overfill prevention in proper operating condition ❑x Yes Z Yes ❑x 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 ❑x Pass ❑Fail ❑xPass ❑Fail 11 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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> hereby certify that the overfill prevention equipment was 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 /> �t <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,AN=Audible and Usual <br />