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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page ;Inspec;tion FTypef Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Mo L FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10182131 12/ 13/2018 Business Name (Same as Facility Name or DBA-Doing Business As) Pilot Flying J 168 Ripon Business Site Address City ZIP Code 1501 N . Jack Tone Rd . Ripon 95366 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Jose Ochoa (888 ) 972 - 7581 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 804431 8004551 - UT 12/27/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW Cert # 100826 Expiration Date : 1 - 19 -2020 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method p Manufacturer Guidelines (specify): UsedUsed tank chart to find 95 % . Inspected Flapper valve at 95 % ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 6 TANK ID : (By tank number, stored product, etc.) Tank- 1 Diesel Tank-2 Diesel Tank-3 Diesel Tank-6 Auto Diesel What is the tank inside diameter? (Inches) 1173/4 of 1173/4 11 1173/4 it 1173/4 It Is the fill piping secondarily contained ? ❑ Yes ix No ❑ Yes ❑x No ❑ Yes E No El Yes ❑x No Is the vent piping secondarily contained ? ❑ Yes E No ❑ Yes ❑x Nox ❑ Yes ❑ No ❑ Yes 2 No Overfill Prevention Equipment Manufacturer(s) Phil-Tite Flapper OPW Flapper OPW Flapper Phil-Tite Flapper 95% 95% 95% 95% What is the overfill prevention equipment response x❑ Shuts Off Flow ❑x Shuts Off Flow x❑ Shuts Off Flow ❑x Shuts Off Flow when activated? (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping? ❑ Yes 0 No ❑ Yes ❑x No ❑ Yes ❑x No El Yes Q No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 107 1 /2 " 1053/8 1053/8 1101 /4 What is the percent capacity of the tank at which the overfill prevention equipment activates? 96 . 24 % 94 . 99 % 94 . 99 % 97 . 86 % Is the overfill prevention in proper operating condition ❑ Yes 0 Yes ❑x Yes ❑ Yes to respond when the substance reaches the appropriate level? Q No (Specify in V.) ❑ No (Specify in V.) ❑ No (Specify in V.) No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass ❑x Fail ❑x Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑x Fail V. COMMENTS Any items marked "Fail" must be explained in this section . Any additional comments may also be provided here. Tank 1 Diesel truck side flapper is set to fully close at 96 . 24% and tank 6 Auto diesel flapper is set to fully close at 97 . 86 % per tank charts . Tank 2 and 3 Diesel truck side flapper are both set to fully close at 94 . 99% of total tank capacity per tank charts . 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 his form accommodates, additional copies of this page maybe attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Usual