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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑Installation Inspection ❑Repair Inspection 0 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181231 2/12/20 Business Name(Same as Facility Name or DBA-Doing Business As) Speedway 4945 Business Site Address City ZIP Code 401 Kettleman Ln. Lodi 95240 fl. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Randy Wilkerson (408)971-2445 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 485184 5258560 1/7/21 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) F.F.#1001093708s � OPW#100593 III. OVERFILL PREVENTIONU P EQ I MENT INSPECTION INFORMATION Inspection Method m Manufacturer Guidelines(Specify): c 2 20{i' Used: OPW � Lb 4 10 ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): ENVIRON"""FeNITAl HEA D�pQr�TltIF��T H Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages TANK ID:(By tank number,stored product,etc.) 87 91 What is the tank inside diameter?(Inches) 98 98 Is the fill piping secondarily contained? 21 Yes ❑No m Yes ❑No ❑Yes ❑No ❑Yes ❑No Is the vent piping secondarily contained? Z Yes ❑No ©Yes ❑No ❑Yes ❑No ❑Yes ❑No Overfill Prevention Equipment Manufacturer(s) OPW OPW What is the overfill prevention equipment response ®Shuts Off Flow when activated?when Off Flow El Shuts Off Flow El Shuts Off Flow (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑AIV Alarm ❑AIV Alarm ❑AIV Alarm ❑AfV Alarm Are flow restrictors installed on vent piping? ❑Yes m No ❑Yes Q No ❑Yes ❑No ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 87.75 82.5 What is the percent capacity of the tank at which the overfill prevention equipment activates? 96% 91.96% Is the overfill prevention in proper operating condition ❑Yes 0 Yes ❑Yes ❑Yes to respond when the substance reaches the appropriate level? _ la 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 m Fail 0 Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail V. COMMENTS Any items marked"Fail"must be explained in this section. Any additional comments may also be provided here. 87 Grade Drop Tube Failed @ 96%.91 Grade Passed but is cut wrong. 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 r� Wthe facility has more components than this form accommodates,additional copies of this page maybe attached. CERS=California En irorrnmtal Reporting System,ID=kientirrcation,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Visual