Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑ Installation Inspection ❑Repair Inspection ®36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID 10184317 Date of Overfill Prevention Equipment Inspection <br /> 9/28/18 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> LOVE'S TRUCK PLAZA <br /> Business Site Address City ZIP Code <br /> 1553 COLONY RD RIPON,CA 95366 <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 /> DAVE WINKLER 209 744 -0112 Ext. <br /> Contractorrrank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 8883059-UT 1-31-20 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW Phil-Tite &EVRPhase 1 1 537 Ex 11-16-18 OPW 104-633 Ex 3-14-2 2 Emco #3207 Ex. -21-202 R:B34 75 ATG:2 8 20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ® Manufacturer Guidelines(Specify) REMOVED DROP TUBE <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 product,etc.) DSL DSL 2 EAS I 871 87 <br /> What is the tank inside diameter?(Inches) 120 120 120 120 <br /> Is the fill piping secondarily contained? ®Yes ❑No M Yes ❑No M Yes ❑ No M Yes ❑ No <br /> Is the vent piping secondarily contained? ®Yes ❑ No ®Yes ❑No M Yes ❑ No M Yes ❑ No <br /> OPW OPW OPW OPW <br /> Overfill Prevention Equipment Manufacturer(s) <br /> 6150 7150 6150 6150 <br /> What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ® Restricts Flow [A Restricts Flow ®Restricts Flow M Restricts Flow <br /> (Check all that apply.) ❑A/V Alarm ❑AN Alarm ❑A/V Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes M No ❑Yes M No ❑Yes M No ❑Yes 12 No <br /> At what level in the tank is the overfill prevention 104 1141/4 115 <br /> set to activate?(Inches from bottom of tank.) 114 <br /> What is the percent capacity of the tank at which 92 95 95 95 <br /> the overfill prevention equipment activates? <br /> Is the overfill prevention in proper operating M Yes [X Yes EVes ®Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results M Pass ❑ Fail I M Pass ❑ Fail ®Pass ❑ Fail ® Pass ❑ Fail <br /> V. COMMENTS <br /> All items marked"Fail'must be explained in this section. Any additional comments may also be provided here. <br /> Imma <br /> N tb <br /> Al1RE <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS IN <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,title 23,division 3, <br /> chapter 16,section 2637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature wi <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=Intemabonal Code Council,AN=Audible and visual <br />