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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection i . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 5/6/2019 Business Name (Same as Facility Name or DBA-Doing Buslness As) Tesoro # 68153 Business Site Address City ZIP Code 2448 W . Kettleman Ln . Lodi 95242 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) Phone # Rey Hernandez 1 (916 373- 1166 Contractor 1 Tank Tester license ;FICC Certification # ICC Certification Expiration pate 617238 8712763 5/8/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Phase 1 EVR - CERT # 0154742 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION inspection Method L] Manufacturer Guidelines (Specify): OPW Install & Maintenance Guidelines Used: ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the Inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, storedproduct, etc.) Gasoline -87 Gasoline - 91 Diesel What is the tank Inside diameter? (Inches) 91 . 625 " 91 , 625" 91 . 625 " Is the fill piping secondarily contained? E Yes [I No R1 Yes E01 No Yes ❑ No ❑ Yes El No Is the vent piping secondarily contained? Z Yes El No Rl Yes ❑ No (] Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) Franklin Fuelin Franklin Fueling Franklin Fueling EBW BBw EBw What is the overfill prevention equipment response R Shuts Off Flow iM Shuts Off Flow M Shuts Off Flow ❑ Shuts Off Flow when activated? El Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑ AN Alarm D AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes ❑R No ❑ Yes 0 No ❑ Yes [A No ❑ Yes ❑ No At what level in the tank Is the overfill prevention set 82 25 „ $2 25 " 82 25u to activate? (inches from bottom of tank.) What is the percent capacity of the tank at which the 95% 95 % 95 % overfill prevention equipment activates? is the overfill prevention in proper operating condition ❑R Yes ❑ Yes :01 Yes ❑ Yesto respond when the substance reaches theappro date 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 El Pass ❑ Fail [g] Pass ❑ Fail D ass ❑ Fail I ❑ Pass ❑ Fall V. COMME14TS Any items marked "Fair must be explained in this section. Any additional comments may also he provided here. Replaced 91 SC , and 87 ,91 and Diesel drop tubes . Performed tightness testing on all drop tubes with passing results . performed pressure decay test with passing results . No audio/lfisual on site Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS iNSPECTiON 1 hereby certify that the overfill prevention equipment was inspected in accordance with California Cade of Regulations, Title 23, Division 3 , Chapter 16, Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature if the facility has more mponents than thf rm accommodates, additional copies of this page maybe attached. CERS = Carifomla Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, [GO = Internal onal Code Council, AN = Audible and Visual