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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection ❑Repair Inspection I]36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10180611 10/16/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> LODI MEMORIAL <br /> Business Site Address City ZIP Code <br /> 975 S FAIRMONT LODI, CA 95240 <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 /> DAVID WINKLER (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2020 <br /> Emco Ex. 10-1-20 VR: B34975 ATG: 2/8/20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines(Specify): <br /> Used: REMOVED DROP TUBE AND PROBE <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 5 <br /> TANK ID: (By tank number,stored product,etc.) suction DSI-tea DSL TANK <br /> What is the tank inside diameter?(Inches) 96 119 <br /> Is the fill piping secondarily contained? ❑Yes [j]No El Yes ❑No ❑Yes ❑No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes El No 0 Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) OPW VR <br /> 61 SO Probe <br /> What is the overfill prevention equipment response 0 Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) ❑ ❑ <br /> Restricts Flow Restricts Flow Restricts Flow El Restricts Flow <br /> ❑A/V Alarm ❑X A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ❑X No ❑Yes IE 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.) 651/2 100 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 73 90 <br /> Is the overfill prevention in proper operating condition 0 Yes Z Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑Fail ❑x 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 h <br /> . : <br /> MAY 2 9 2020 <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTI_{U��,'7,11;JN, -T—G.fTIQN JEALTH <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California C60of 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,AA/=Audible and Usual <br />