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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑x Installation Inspection ❑x Repair Inspection ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID 10182131 Date of Overfill Prevention Equipment Inspection <br /> 4/24/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Pilot Flying J 618 Ripon <br /> Business Site Address City ZIP Code <br /> 1501 N Jack Tone Rd. Ripon 95366 <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 /> Jose Ochoa (888) 972-7581 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804431 8004551-UT 12/27/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FFS Cert# 1002753709 Expiration Date: 10-4-2019 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Manufacturer (specify): <br /> Used: Used tank chart to find 95%. Installed Flapper valve at 95% <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.) T-1 Bio T-2 87 T-3 91 <br /> What is the tank inside diameter?(inches) 118 3/8" 117 3/4" 117 3/4" <br /> Is the fill piping secondarily contained? Oyes ❑No Dyes ❑X No Dyes 0No Dyes ❑No <br /> Is the vent piping secondarily contained? OYes ❑No Dyes ❑X No Dyes [H]No Dyes [:]No <br /> Overfill Prevention Equipment Manufacturer(s) OPW Flapper FFS Defender FFS Defender <br /> 95% 95% 95% <br /> What is the overfill prevention equipment response 0 Shuts Off Flow 0 Shuts Off Flow Q Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑ Restricts Flow <br /> ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? Dyes ZNo Dyes ONo Dyes NNo ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 106 1/4" 104 7/8" 104 7/8" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95% 95% 95% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x Yes Dyes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No (Specify in V.) ❑No (Specify in V.) ❑No (Specify in V.) El No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results TE—]Pass ❑Fail I ❑x Pass ❑Fail I ❑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 equipment was inspected in accordance with California Code of Regulations,Title2 3, <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 his form accommodates,additional copies of this page maybe attached. <br /> CERS=Cal'rfomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AA/=Audible and Visual <br />