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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pane t of1 ) Type of Action ❑ Installation inspection El Repair inspection ® 30 Month Inspoction I • FACILITY INFORMATION CERS ID 10180541 Date of Overfill Prevention Equipment Inspocdlon 1011 /2018 Business Namo (Same as Facility Nemo or DBA-Doing Business As) Joes Travel Plaza Business Site Address City ZiP Code 15600 S Harlan Rd Lathrop 95330 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone it David Winkler 209 744-0112 Contractor i Tank Tester License it ICC Certification # ICC Certification Expiration Date 08- 1739 Ex . 3/31 /2020 8883059- UT 1 /29/2020 Overfill Prevention Equipment inspection Training and Certifications (list applicable certifications.) FF- EBW , PhikTite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 104-633 Ex 3- 14-2020 Emco #3207 Ex . 09-21 -2020 VR: 834975 ATG : 2/8/20 Ill . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION inspection Method 0 Manufacturer Guidelines (Specify): Used : Removed Drop Tubes ❑ Industry Code or Engineering Standard (Specify): ❑ Engineered Method (Specify): Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 5 TANK ID : (By tank number, stored product, etc.) 87 W 87 E 91 DSL What is the tank inside diameter? (Inches) 114 95 114 114 Is the fill piping secondarily contained? ❑ Yes R No ❑ Yes 9 No ❑ Yes 0 No ❑ Yes 21 No Is the vent piping secondarily contained? 0 Yes ❑ No [E Yes ❑ No B Yes ❑ No [R Yes ❑ No Overfill Prevention Equipment Manufacturer(s) oPw OPW OPW OPW 61 - SO 61 - SO 61 - SO 61 - SO What Is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? ❑x Restricts Flow El Restricts Flow ❑x Restricts Flow 91 Restricts Flow (Check all that apply.) ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes ❑x No ❑ Yes B No ❑ Yes iE No ❑ Yes 9 No At what level in the tank is the overfill prevention set to activate? (inches from bottom of tank.) 99 . 5 85 10621 /4 97 1 /2 What is the percent capacity of the tank at which the 92 94 94 91 overfill prevention equipment activates? Is the overfill prevention in proper operating condition ❑x Yes I] Yes 0 Yes 0 Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V,) ❑ No (Specifyin V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Q Pass ❑ Fail ❑x Pass ❑ Fail ❑x 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 = Ca6(omia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual