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UNDERGROUND STORAGE TANK <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, <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Overfill Prevention Equipment Inspection <br />10180627 <br />1/11/2019 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />CHEROKEE LANE SERVICE <br />Business Site Address <br />City <br />ZIP Code <br />900 S. CHEROKEE LANE <br />LODI <br />95242 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) <br />Phone # <br />Zane Nimmo <br />(209) 744-0112 <br />Contractor I Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />04-1676 Ex.03/31/2019 <br />8883064-UT <br />6/1/2019 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />FF- EBW PhikTite & EVR Phase 1 10009843708 Ex 11-29-20 OPW 104-632 Ex 3-14-2020 <br />, <br />Emco 3206 Ex. 11/14/2020 ATG: VR: A28446 Ex, 9/28/19 Incon # 1009843708 Ex. 11-30-20 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Zx Manufacturer Guidelines (Specify): <br />OPW PHASE I TESTING <br />Used: <br />❑ Industry Code or Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages 6 <br />TANK ID: (By tank number, storedproduct, etc.) <br />1 - 87-A <br />2 - 91 OCT <br />3 -87-13.14- <br />DIESEL <br />What is the tank inside diameter? (Inches) <br />128.0 <br />128.0 <br />128.0 <br />128.0 <br />Is the fill piping secondarily contained? <br />Z Yes ❑x No <br />❑ Yes ❑x No <br />❑ Yes Z No <br />❑ Yes ❑x No <br />Is the vent piping secondarily contained? <br />Z Yes Z No <br />❑ Yes Z No <br />❑ Yes Z No <br />❑ Yes Z No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW <br />O P W <br />o P W <br />O P W <br />What is the overfill prevention equipment response <br />Zx Shuts Off Flow <br />❑x Shuts Off Flow <br />Z Shuts Off Flow <br />x❑ Shuts Off Flow <br />when activated? <br />❑ Restricts Flow <br />El Restricts Flow <br />El Restricts Flow <br />E] Restricts Flow <br />(Check all that apply.) <br />❑ AN Alarm <br />❑ AN Alarm <br />❑ AN Alarm <br />❑ AN Alarm <br />Are flow restrictors installed on vent piping? <br />Z Yes Z No <br />❑ Yes ❑x No <br />❑ Yes 0 No <br />❑ Yes Z No <br />At what level in the tank is the overfill prevention set <br />113.5 <br />114.0 <br />115.5 <br />121.0 <br />to activate? (Inches from bottom of tank.) <br />What is the percent capacity of the tank at which the <br />93% <br />94% <br />95% <br />97% <br />overfill prevention equipment activates? <br />Is the overfill prevention in proper operating condition Z Yes Z Yes Z Yes ElYes <br />to respond when the substance reaches the <br />appropriate level? ElNo (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) Z No (Specify in V.) <br />IV. SUMMARY OF INSPECTION RESULTS <br />Overfill Prevention Inspection Results <br />Z Pass ElFail Z Pass ❑Fail <br />Z Pass ElFail <br />[:]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 />DIESEL TUBE SET TOO HIGHJr <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I hereby certify that the overfill prevention equipment was inspected in accordance yy 1h Cal)f4 i,, od of gplations, Title 23, <br />,x,06 �.r�I�IIe�r,�$ <br />Division 3, Chapter 16, Section 2637.2��and all the information contained herein is ccu'ra1e. <br />UST Service Technician Signature c T <br />AN =Audible and Usual <br />