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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of i) Type of Action ❑ Installation Inspection ❑ Repair Inspection Q 36 Month Inspection 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 1 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 Ili. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines{Specify}: Used: Used 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-8 Bio-Diesel Tank-4 87 Tank-5 91 What is the tank inside diameter?(Inches) 118 318" 117 314" 117 314" Is the fill piping secondarily contained? ❑x Yes ❑No ❑Yes 0 No ❑Yes ❑x No ❑Yes ❑Na Is the vent piping secondarily contained? ❑x Yes ❑ No ❑Yes ❑x No ❑Yes El No ❑Yes ❑No Overfill Prevention Equipment Manufacturers) OPW Flapper Phil-Tice Flapper Phil-Fite Flapper 95% 95% 95% What is the overfill prevention equipment response ❑x Shuts Off Flow x❑Shuts Off Flow ❑x Shuts Off Flow ❑Shuts Off Flow when activated? (Check all that apply.) EI Restricts Flow ❑ Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑AIV Alarm ❑AIV Alarm ❑AIV Alarm ❑AN Alarm Are Flow restrictors installed on vent piping? ❑Yes E No ❑Yes N No ❑Yes ❑x No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 109 314" 110" 108° What is the percent capacity of the tank at which the overfill prevention equipment activates? 97% 96.74% 96.76% Is the overfill prevention in proper operating condition ❑Yes ❑Yes ❑Yes ❑Yes to respond when the substance reaches the appropriate level? N No(Specify in V.) ❑x No(Specify in V.) I [E No(Specify in V.) ❑No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass ❑x Fail ❑Pass N Fail ❑Pass X Fail ❑Pass ❑Fail V. COMMENTS Any items marked"Fail'most be explained in this section. Any additional comments may also be provided here. Tank#8 Bio-Diesel flapper is set at 97%, Tank#4 87 flapper is set at 96.74% and Tank#5 91flapper is set at 96.76%. 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 Zisform accommodates,additional copies of this page maybe attached. CERS=California Environmental Reporting System.ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AIV=Audible and Usual