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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 11/13/2019 <br />Business Name Arco <br />Business Site Address 255 E Harney Lane <br />City Lodi <br />Zip Code <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of Service Technician (on ICC Certification) Darnell Smith <br />Phone # 916-371-2380 <br />Contractor License #: 433159 ICC Certification: 8709494 <br />ICC Expiration Date: 12/21/2019 <br />Overfill Prevention Equipment Relevant Certifications (List Applicable): <br />VR TLS 3xx - B48857 ex 3/29/20 <br />Ill. 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 aff documentation required to determine the results. # of attached pages: <br />Tank ID: (By tank number, stored <br />91 <br />DSL <br />87 <br />What is the tank inside diameter? (inches) <br />118" <br />118" <br />118" <br />Is the Fill Piping Secondarily contained? <br />Is the Vent Piping Secondarily contained? <br />® Yes ❑ No <br />® Yes ❑ No <br />®Yes ❑ No <br />® Yes ❑ No <br />®Yes ❑ No <br />® Yes E] No <br />❑Yes E] No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment <br />Manufacturer <br />Probe <br />Probe <br />Probe <br />Tank Manufacturer <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 />® A/V Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />® A/V 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 N 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 3/4" <br />99 3/4" <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 />® 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 provided here. <br />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I 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 Si <br />