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UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM <br />Type of Action: ❑ Installation Inspection ❑ Repair Inspection ® 36 Month inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />Date of Overfill Prevention Equipment <br />Inspection 7/19/2019 <br />Business Name Arco AmPm- Harney <br />Business Site Address 255 E Harney Ln <br />City Lodi <br />Zip Code <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Service Technician (on ICC Certification) Timothy Burkart <br />Phone # 916-371-2380 <br />Contractor License #: 433159 ICC Certification: 00210960 ICC Expiration Date: 3/28/2021 <br />Overfill Prevention Equipment Relevant Certifications (List Applicable): <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />❑ Manufacturer Guidelines (Specify): <br />Used: <br />® Industry Code or Engineering Standard (Specify): PEI 1200 Pg.18 <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. # of attached pages: <br />Tank ID: (By tank number, stored <br />87 <br />91 <br />DSL <br />What is the tank inside diameter? (inches) <br />118.38 <br />118.38 <br />118.38 <br />Is the Fill Piping Secondarily contained? <br />® Yes ❑ No <br />® Yes ❑ No <br />® Yes ❑ No <br />[]Yes ❑ No <br />Is the Vent Piping Secondarily contained? <br />® Yes ❑ No <br />® Yes ❑ No <br />® Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment <br />Manufacturer <br />OPW <br />OPW <br />OPW <br />Tank Manufacturer <br />Xerxes <br />Xerxes <br />Xerxes <br />What is the overfill prevention equipment <br />response when activated? <br />(Check all that apply) <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />® A/V Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />® AN Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />® AN Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ A/V Alarm <br />Are flow restrictors installed on vent <br />piping? <br />❑ Yes ® No <br />❑ Yes ® No <br />❑ Yes ® No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill <br />prevention set to activate? (Inches from <br />bottom of tank.) <br />99 1/4" <br />985/81, <br />99 3/4" <br />What is the percent capacity of the tank at <br />which the overfill prevention equipment <br />activates? <br />90% <br />90% <br />90% <br />Is the overfill prevention in proper <br />operating condition to respond when the <br />substance reaches the appropriate level? <br />® Yes <br />❑ No (Specify in V.) <br />® Yes <br />❑ No (Specify in V.) <br />® Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />IV. SUMMARY OF <br />INSPECTION RESULTS <br />Overfill Prevention Inspection Results ® Pass ❑ Fail <br />I ® Pass ❑ Fail ® Pass [—]Fail ❑ Pass ❑ Fail <br />V. COMMENTS <br />Any items marked "Fail' must be explained in this section. Any additional comments may also be pro <br />vNt U E, } <br />t� tf ,� <br />A)F,, <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I hereby certify that the overfill prevention equipment was inspected in accordance wit +1fp �9�j f Regulations, Title 23, <br />Division 3, Chapter 16, Section 2637.2 and all the information contained herein is accurate V'�' V 1pjI��H� i i ",'' <br />UST Service Technician Signature DEPARTMENT <br />