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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181397 1/29/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> EF KLUDT Test Form 2 of 2 <br /> Business Site Address City ZIP Code <br /> 1126 E PINE ST LODI 95241 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Edward Stearns (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 14-1760 Ex. 09/30/2020 8883080-UT 11/9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009893708 Ex 11/29/2020 OPW 104-635 Ex 3-14-2020 <br /> Emco 3205 Ex. 11/16/2020 ATG: VR A31048 Ex.8/9/19 Incon 1009893708 11/30/2020 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): REMOVED AND INSPECTED <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 5 <br /> TANK ID: (By tank number,stored product,etc.) 1- CLEAR DI 4- KEROSENE <br /> What is the tank inside diameter?(Inches) 128 75.50 <br /> Is the fill piping secondarily contained? ❑Yes EI No ❑Yes ❑x No ❑Yes ❑No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes ❑x No ❑Yes ❑x No ❑Yes ❑No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow I]Shuts Off Flow ❑Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑ Restricts Flow <br /> ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes 0 No ❑Yes ❑ No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 116 67 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 92 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑Yes ❑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 11 ❑x Pass ❑ Fail 11 ❑x 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 Signature <br /> If the facility has 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,AA/=Audible and Visual <br />