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190325-003 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION ;EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑✓ 36 Month Inspection <br /> Is FACILITY INFORMATION <br /> CERS ID ----] Date of Overfill Prevention Equipment Inspection <br /> 10403278 03 -25 -2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Lodi CA FO Term (Intl) <br /> Business Site Address City ZIP Code <br /> 2500 West Turner Road Lodi 95242 <br /> Ila UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Kraig Kinder 888-588-8737 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 703190 18296393 12/7/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Franklin Fueling Spill Prevention <br /> 111 . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑✓ Manufacturer Guidelines (Specify) : OPW <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. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) Tank4 /Diesle <br /> What is the tank inside diameter? (inches) 71 .625 " <br /> Is the fill piping secondarily contained ? ❑ Yes ✓❑ No ❑ Yes ❑ No ❑ Yes ❑ No LI Yes U No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑✓ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW <br /> i <br /> What is the overfill prevention equipment response ❑✓ Shuts Off Flow ElShuts Off Flow ElShuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ✓❑ Restricts Flow E] Restricts Flow 171Restricts Flow ElRestricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping? ✓❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set 64. 5 <br /> to activate? (inches from bottom of tank.) <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 <br /> Is the overfill prevention in proper operating condition ✓❑ Yes ❑ 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 /> 1V. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑✓ 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 /> VL 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 Signature Digireuy signed by Kraig Kinder <br /> Kraig Kinder Date: 2019.03.2514:2e:55 -07'00' <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, A/V = Audible and Visual <br /> QA/QC APPROVED <br /> 3/29/20199 : 11 AMTeresa Ant <br />