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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 Q 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10184349 12/ 18/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Pilot Flying J 617 Lodi <br /> Business Site Address City ZIP Code <br /> 15100 N . Thornton Road Lodi 95242 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the /CC Certification.) Phone # <br /> Jose Ochoa 1 (888 ) 972 - 7581 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 804431 8004551 - UT 12/27/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> Philtite 1002753709 exp 10 . 03 . 2019 ICC 8004551 exp12 . 26 . 19 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Manufacturer Guidelines (specify) : <br /> Used : Used tank chart to find 95 % . Inspected Flapper valve at 95 % <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 <br /> TANK ID : (By tank number, stored product, etc.) Tank-5 91 <br /> What is the tank inside diameter? (Inches) 1173/4 <br /> Is the fill piping secondarily contained? Z Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) PhikTiite Flapper <br /> 95% <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated? <br /> ❑ <br /> (Check all that apply.) Restricts Flow El Restricts Flow ['1 Restricts Flow El Restricts Flow <br /> ❑ AIV Alarm ❑ A/V Alarm ❑ AIV Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (inches from bottom of tank.) 1027/8 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 9172 % <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑ Yes ❑ Yes ❑ Yes <br /> to respond when the substance reaches the <br /> appropriate level? I ❑ 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 ❑Q Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <br /> Tank#5 91 flapper is set at 93 . 72% . Unable to check for ball floats . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23 , <br /> Division 3, Chapter 16, Section 2637 .2 and all the information contained herein is accurate . <br /> UST Service Technician Signature <br /> If the facility has more components than zisform accommodates, additional copies of this page maybe attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, A/V = Audible and Visual <br /> I <br />