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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page I of 1) <br /> TypeA ❑Installation inspection x 36 Month Inspection <br /> p ❑Repair Inspection ❑ <br /> ` CERS ID I. FACILITY INFORMATION <br /> 10448341 Date of Overfill Prevention Equipment Inspection <br /> 9/26/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Love's Fuel Center ZIP Code <br /> Business Site Address city 95242 <br /> 15250 N Thornton Rd Lodi <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> David Winkler <br /> (209) 744-0112 <br /> Contractor i Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite &EVR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2020 <br /> Emco #3207 Ex.09-21-2020 VR: B34975 ATG: 2/8/20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method x❑Manufacturer Guidelines(Specify): Removed Probes <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> #of Attached Pages <br /> Attach the inspection procedures and all documentation required to determine the results. 5 <br /> TANK ID:(By tank number,stored product,etc.) 87 91 DSL <br /> What is the tank inside diameter?(inches) 118.38 118.38 118.38 <br /> Is the fill piping secondarily contained? [D Yes ❑No x❑Yes ❑No ❑x Yes ❑No ❑Yes ❑No <br /> 'v Is the vent piping secondarily contained? Yes ❑No ❑x Yes ❑No 0 Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root <br /> Probes Probes Probes <br /> What is the overfill prevention equipment response ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow C]Restricts Flow [I Restricts Flow ❑Restricts Flow <br /> (]AN Alarm AN Alarm ❑x AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes [E]No ❑Yes [E No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 99 98 98 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 90 90 <br /> Is the overfill prevention in proper operating condition ❑x Yes x❑Yes ❑x Yes <br /> to respond when the substance reaches the ❑Yes <br /> [Iappropriate level? No(Specify in V) ❑No(Specify in V) C]No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results FIE-pass ❑Fail Q Pass ❑Fail ❑x 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 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 /> :-�W UST Service Technician Signature T&- 1 <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=CaVwja Environ mental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Cour-d,AN=A Bible and Visual <br />