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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection 1. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10180541 10/1/2018 Business Name(Same as Facility Name or DBA-Doing Business As) Joes Travel Plaza Business Site Address City ZIP Code 15600 S Harlan Rd Lathrop 95330 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the/CC Certification) Phone# David Winkler 1 (209) 744-0112 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) FF- EBW, Phil-Tite & EVR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2020 Emco #3207 Ex. 09-21-2020 VR: B34975 ATG:2/8/20 III. OVERFILL PREVENTION EQUIPMENT INSPECTION IN N Inspection Method ❑x Manufacturer Guidelines(Specify): Used: Removed Drop Tubes FEB 12 R19 ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): ENVIRONMENTAL HEALT Attach the inspection procedures and all documentation required to determine the results. #of 1MFPAPb-6W=N 15 TANK ID:(By tank number,stored product,etc.) 87 W 87 E 91 DSL What is the tank inside diameter?(Inches) 114 95 114 114 Is the fill piping secondarily contained? ❑Yes ❑x No ❑Yes ❑x No ❑Yes I] No ❑Yes 0 No Is the vent piping secondarily contained? Exl Yes ❑No ❑x Yes ❑No 0 Yes ❑No ❑x Yes ❑No Overfill Prevention Equipment Manufacturer(s) oPw OPw oPw oPw 61-SO 61-SO 61-SO 61-SO 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.) ARestricts Flow 9Restricts Flow 0 Restricts Flow [ERestricts Flow ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm Are flow restrictors installed on vent piping? ❑Yes (]No ❑Yes E No ❑Yes 0 No ❑Yes Eig No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 99.5 85 10621/4 971/2 What is the percent capacity of the tank at which the overfill prevention equipment activates? 92 94 94 91 Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes ❑x Yes to respond when the substance reaches the El level? No(Specify in V.) ❑ No(Specify in V.) No(Specify in V.) No(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑x Pass ❑Fail ❑x Pass ❑Fail 11 ❑x Pass ❑Fail ❑x Pass ❑Fail V. COMMENTS Any items marked"Fair must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature V z� -"' If the facility has more components than this form accommodates,additional copies of this page may be attached. CERS=Ca6fomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AA1=Audible and Visual