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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection I. FACILITY INFORMATION CERS ID 10181407 Date of Overfill Prevention Equipment Inspection 04/17/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Kwik Sery#113 Business Site Address City ZIP Code 420 W. Kettleman Lane Lodi 95240 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Steven White (408)971-2445 Contractor!Tank Tester License# ICC Certification# ICC Certification Expiration Date 485184 8898679 05/10/20 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) 1016243710 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ® Manufacturer Guidelineseci S( p �) OPW Manual Used: ❑ Industry Code or Engineering Standard(Specify): ❑ Engineered Method (Specify): 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 Diesel E85 What is the tank inside diameter?(Inches) 120 120 120 120 Is the fill piping secondarily contained? ❑ Yes ✓❑ No ❑Yes © No ❑Yes © No ❑Yes ✓❑ No Is the vent piping secondarily contained? ❑Yes © No ❑Yes ❑✓ No ❑Yes ® No ❑Yes © No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW OPW What is the overfill prevention equipment response ❑ Shuts Off Flow ❑Shuts Off Flow ❑ Shuts Off Flow ❑ 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 ❑✓ No ❑Yes ❑✓ No ❑Yes ® No ❑Yes ®No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? Is the overfill prevention in proper operating condition ❑Yes ❑Yes ❑Yes ❑Yes to respond when the substance reaches the appropriate level? ❑ 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 11 ❑ Pass ❑x Fail 11 ❑ Pass ❑x Fail ❑ Pass E Fail V. COMMENTS Any items marked"Fail"must be explained in this section. Any additional comments may also be provided here. "Could not remove 87,91 and Diesel Drop Tubes due to stuck risers on 87/91 and stuck Adaptor/riser on Diesel.Was able to verify functioning flapper on the E85 but could not locate the tank chart for that tank. lviM 9 'i Lj ly 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 thanthis form�accommodates,additional copies of this page may be attached. CERS=California Environmental Reporting System.ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AA/=Audible and Visual