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UNDERGROJ TO)tAGE TANK OVERFILL PREVENTION EQUIPMENT APECTION-REPORT FORM (Page 1 of 1) Type of Action ❑ Installation inspection ❑ Repair Inspection " ' ®36 Month inspection I. FACILITY INFORMATION ERS ID Date of Overfill Prevention Equipment Inspection 10181549 �V/RO 110/12/2018 Business Name(Same as Facility Name or DBA-Doing Business As.) D�-p4zlVTqt H Lodi Muni Service Center, City of Lodi A T Eq Business Site Address a ZIP Code 1331 S. Ham 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# Eric Mol acrd 209 367-4800 Ext. Contractorfrank Tester License# ICC Certification# ICC Certification Expiration Date 774802 18881020 102/25/2019 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) OP LIST/AST& Veeder Root#AZ7995 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: D Manufacturer Guidelines(Specify) M Industry Code or Engineering Standard (Specify)PEI/RP1200-17 ❑Engineered Method(Specify) Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages: 11 Tank ID: (By tank number,stored product,etc.) 204-10k-Gas 207-Sk-DSI 208-2k-Gas What is the tank inside diameter?(inches) 92 92 75. 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 Veeder Root OPW Veeder Root Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment ❑Shuts Off Flow ®Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow (Check all that apply.) ®A/V 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 77 83 56 set to activate?(inches from bottom of tank.) What is the percent capacity of the tank at which 90 95 80 the overfill prevention equipment activates? Is the overfill prevention in proper operating ®Yes ®Yes ®Yes ❑Yes condition to respond when the substance ❑No ❑No ❑No ❑No reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ®Pass ❑Fail ®Pass ❑Fail ®Pass ❑Fail ❑Pass ❑Fail V. COMMENTS All items markedJ�FCEhlrmn ust be explained in thhis section. Any additional comments may also be ere. SEP 2 0 2019 / 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 Info ation talned herein Is accurate. UST Service Technician Si if the facility has more components than this form accommodates,additional copies of this page may be attached- CERS=C&%rnb EnvimnmrnW Repotiiug Systan,ED=Idmtificatkon,UST=UndaWound stwW tank,ICC=In6anadomt Code Council,AN=Andible and%is"