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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page -I of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10182257 2/6/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> WINE COUNTRY 76 <br /> Business Site Address City ZIP Code <br /> 1111 E KETTLEMEN LANE Lodi 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 , PhikTite & EVR Phase 1 1009853708 Ex 11 /29/20 OPW 104-633 Ex 3 - 14-2020 <br /> Emco #3207 Ex . 11 / 16/20 ATG : VR : B34975 ATG : 2/8/20 INCON 1009853708 Ex . 11 /30/2020 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : REMOVED DROP TUBES <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. --r#-of Attached Pages 4 <br /> TANK ID : (Bytanknumber, storedproduct, etc.) 87 91 DSL <br /> What is the tank inside diameter? (Inches) 95 95 95 <br /> Is the fill piping secondarily contained? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes H No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW oPw oPw <br /> 61SO 61So 61so <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow Z Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ AIV Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes M No ❑ Yes ❑x No ❑ Yes H No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 85 86 76 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 94 94 85 <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes I] 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 0 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 commentIso bq prpvided�rr <br /> R <br /> , i � ii 7 <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> hereby certify that the overfill prevention equipment was inspected in accordarlb \M�ri6148,..ttS1 ` bE� of j2e� lat� c ns , Title 23, <br /> Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurp <br /> UST Service Technician Signature V <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 />