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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 0 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10448341 9/26/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Love ' s Fuel Center <br /> Business Site Address City ZIP Code <br /> 15250 N Thornton Rd Lodi 95242 <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 #3207 Ex . 09-21 -2020 VR : B34975 ATG : 2/8/20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : Removed Probes <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. —P# -of Attached Pages 5 <br /> TANK ID : (By tank number, stored product, etc.) 87 91 DSL <br /> What is the tank inside diameter? (Inches) 118 . 38 118 . 38 118 . 38 <br /> Is the fill piping secondarily contained? ❑x Yes ❑ No M Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? Z Yes ❑ No 0 Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Veeder Root Veeder Root Veeder Root <br /> Probes Probes Probes <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> Z AIV Alarm x A/V Alarm 0 AIV Alarm ElAIV Alarm <br /> Are flow restrictors installed on vent piping ? ElYes 0 No ElYes N No ❑ Yes R No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 99 98 98 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 90 90 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x 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 0 Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail' must be explained in this section . Any additional comments may also be pjNtf��'dbd3Q <br /> HiIV3H WiNEIWNOHIANEI <br /> 6 07 0 1 ddv <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance w iaflifoXnia Code of Reg ylgtiohsu <br /> a 23 , <br /> Division 3 , Chapter 16 , Section 2637. 2 and all the information contained herein is acur te . ^ _sj <br /> UST Service Technician Signature V <br /> If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Usual <br />