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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM <br /> Type of Action: ❑Installation Inspection ❑Repair Inspection N 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment <br /> Inspection 11/15/2018 <br /> Business Name George Kishida Trucking <br /> Business Site Address 1725 Ackerman Dr. City Lodi Zip Code <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Service Technician(on ICC Certification) Rhome Desbiens Phone# 916-371-2380 <br /> Contractor License#: 433159 ICC Certification: 5244364 ICC Expiration Date: 1/5/2019 <br /> Overfill Prevention Equipment Relevant Certifications(List Applicable): <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑Manufacturer Guidelines(Specify): <br /> Used: <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 <br /> Tank ID:(By tank number,stored DSL-1 DSL-2 <br /> What is the tank inside diameter?(inches) 90.5" 90.5" <br /> Is the Fill Piping Secondarily contained? ❑Yes N No ❑Yes N No ❑Yes ❑No ❑Yes ❑No <br /> Is the Vent Piping Secondarily contained? ❑Yes N No ❑Yes N No ❑Yes ❑No ❑Yes <br /> ❑No <br /> Overfill Prevention Equipment OPW OPW <br /> Manufacturer <br /> Tank Manufacturer Flapper Flapper <br /> What is the overfill prevention equipment ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? N Restricts Flow N Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> (Check all that apply) ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm <br /> Are flow restrictors installed on vent ❑Yes N No ❑Yes N No ❑Yes ❑No <br /> El Yes ❑No <br /> piping? <br /> At what level in the tank is the overfill <br /> prevention set to activate?(Inches from 81" 77" <br /> bottom of tank.) <br /> What is the percent capacity of the tank at <br /> which the overfill prevention equipment 92% 85% <br /> activates? <br /> Is the overfill prevention in proper ®Yes ®Yes ❑Yes ❑Yes <br /> operating condition to respond when theeci <br /> ElNo(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> substance reaches the appropriate level? <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results N Pass ❑Fail N Pass ElFail ❑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 /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained he:eiii is accurate <br /> UST Service Technician Signature <br />