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F Z J 1 1 UNDERGROUND STORAGE TANk 47 2019 OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10184349 12/ 18/2018 Business Name (Same as Facility Name or DBA-Doing Business As) Pilot Flying J 617 Lodi Business Site Address City ZIP Code 15100 N . Thornton Road Lodi 95242 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Jose Ochoa ( 888 ) 972 - 7581 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 804431 8004551 - UT 12/27/2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Philtite 1002753709 exp 10 . 03 . 2019 ICC 8004551 exp12 . 26 . 19 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method p Manufacturer Guidelines (specify): Used : Used tank chart to find 95 % . Inspected Flapper valve at 95 % ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID : (By tank number, stored product, etc.) Tank- 1 87 Tank-2 87 Tank- 3 87 Tank4 87 What is the tank inside diameter? (Inches) 1173/4 1173/4 1173/4 1173/4 If Is the fill piping secondarily contained? ❑x Yes ❑ No ❑x Yes ❑ No R Yes ❑ No R Yes ❑ No Is the vent piping secondarily contained? ❑x Yes ❑ No R Yes ❑ No R Yes ❑ No R Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW Flapper OPW Flapper OPW Flapper Phil-Tite 95% 95% 95% 95% What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow 0 Shuts Off Flow ❑x Shuts Off Flow when activated ? ❑ (Check all that apply) Restricts Flow E] Restricts Flow El Restricts Flow El 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 „ „ „ it to activate? (Inches from bottom of tank.) 1073/8 1053/8 1053/8 1023/8 What is the percent capacity of the tank at which the overfill prevention equipment activates? 96 . 16 % 94 . 99 % 94 . 99 % 93 % Is the overfill prevention in proper operating condition ❑ Yes (] Yes Yes ❑x Yes to respond when the substance reaches the appropriate level? ❑x 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 0 Fail I ❑x Pass ❑ Fail Z Pass ❑ Fail ❑x Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here . Tank 1 87 fail . Drop tube is set to fully close at 96 . 16% of tank full capacity per tank chart . Tank 4 flapper valve is set to fully close at 93% of full tank capacity . Tank 2 and 3 are both set to fully close at 94 . 99% of full tank capacity per tank charts . Unable to check for ball floats . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas 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 than 1hisform accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Visual