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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection X 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10182153 12 / 11 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) LATHROP GAS & FOOD Business Site Address City ZIP Code 140 E . LATHROP ROAD LATHROP 95330 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Zane Nimmo ( 209 ) 744 -0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 03/31 /2019 8883064- UT 6/ 1 /2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 10009843708 Ex 11 -29-20 OPW 104-632 Ex 3- 14-2020 Emco 3206 Ex . 11 / 14/2020 ATG : VR : A28446 Ex . 9/28/ 19 Incon # 1009843708 Ex . 11 -30-20 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : O P W PHASE ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID : (By tank number, stored product, etc.) 1 - 87 OCT 2 - 91 OCT 3 - D S L What is the tank inside diameter? (Inches) 96 , 0 " 96 . 0 " 96 . 0 " Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes Z No ❑ Yes E No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes ❑x No ❑ Yes N No ❑ Yes ❑x No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) oPw o P W o P W What is the overfill prevention equipment response Z Shuts Off Flow ❑x Shuts Off Flow X Shuts Off Flow ❑ Shuts Off Flow when activated ? ❑ (Check all that apply.) Restricts Flow ❑ Restricts Flow El Restricts Flow El Restricts Flow ❑ A/V Alarm ❑ AA/ Alarm E] A/V Alarm El AIV Alarm Are flow restrictors installed on vent piping ? ❑ Yes Z No ❑ Yes ZNo ElYes 0 No ❑ Yes [:1No At what level in the tank is the overfill prevention set � � „ to activate? (Inches from bottom of tank.) 86 . 0 83 . 5 „ 84 . 5 What is the percent capacity of the tank at which the overfill prevention equipment activates? 94 % 92 % 93 % Is the overfill prevention in proper operating condition 0 Yes ❑x Yes ❑x Yes ❑ Yes to respond when the substance reaches the appropriate level ? El No (Specify in V.) El No (Specify in V.) ❑ No (Specify in V.) [I No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑x Pass ❑ Fail x❑ Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail” must be explained in this section. Any additional comments may also be provided here. VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code 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 components than this form accommodates, additional copies of this page maybe attached. CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual