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01 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel of 1 ) <br /> Type of Action Z Installation Inspection ❑ Repair Inspection [:136 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 06-29-2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Verizon Business <br /> Business Site Address City ZIP Code <br /> 2500 W. Turner Rd Lodi 95242 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) Phone # <br /> John Cascio 1 916-858- 1090 <br /> Contractor / Tank Tester License # T5252163 ' <br /> C Certication # ICC Certification Expiration Date <br /> 588098 09-25-2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> OPW Phase 1 , 101159 , 08-25-2019 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑ Manufacturer Guidelines (Specify) : <br /> Used : <br /> ❑x Industry Code or Engineering Standard (Specify) : PEI RP- 1200 <br /> ❑ Engineered Method (Specify) : <br /> ection procedures and all documentation required to determine the results. # of Attached Pages 5 <br /> Attach the insp p <br /> TANK ID : (By tank number, stored product, etc.) Diesel <br /> What is the tank inside diameter? (Inches) 71 5/8" <br /> Is the fill piping secondarily contained ? ❑ Yes p No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes E No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW 71 SOT <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) El Restricts Flow C] Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ AA/ Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set 641 /2 <br /> to activate? (Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the 95% <br /> overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating condition [g] Yes El Yes El Yes El Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑Q Pass ❑ Fail ❑ 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 /> Flow restrictors not investigated at this time . <br /> Check If Action Item (s) Are Present <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas 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 Signature <br /> If the facility as 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, AN = Audible and Visual <br />