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' UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page t of t) <br /> Type of Action ® Installation Inspection ® Repair Inspection ❑ 36 Month Inspection <br /> Is FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181231 03/27/20 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Speedway 4945 <br /> Business Site Address City ZIP Code <br /> 401 W Kettleman Ln . Lodi 95240 <br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Brian McPheely 4089712445 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8822062 11 /01 /21 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> OPW # 104773 <br /> Franklin Fueling Site Safety # 1014303708 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ® Manufacturer Guidelines (Specify): OPW 71 SO <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.) 1 -87 2-91 <br /> What is the tank inside diameter? (Inches) 96 96 <br /> Is the fill piping secondarily contained? ❑ Yes 0 No ❑ Yes © No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes © No ❑ Yes ✓❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> 71 SO 71 SO <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 El Restricts Flow ❑ Restricts Flow C] Restricts Flow <br /> ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes © No ❑ Yes F71 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.) 84 83 .872 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 92. 78%a 92. 675% <br /> Is the overfill prevention in proper operating condition ® Yes ® Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? [INo (Specify in V.) El No (Specify in V.) El No (Specify in V.) ElNo (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail ® 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 /> Replaced 87 and 91 Drop Tubes - Tested & Passed . <br /> I If <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING 'THISINSPECTION <br /> 1 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, AN = Audible and Visual <br />