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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type of Action E Installation Inspection ❑ Repair Inspection ❑ 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181545 04/10/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As,) <br /> San Joaquin County Pubic Works Corp Yard <br /> Business Site Address City ZIP Code <br /> 1810 E Hazelton Ave Stockton 195205 <br /> 11 . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Nicholas Graham -Lewin 209 367 . 4800 Ext. <br /> Contractorfrank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 774802 11 8897286 05/21 /2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable cert cations.) <br /> QPW <br /> 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: ❑ Manufacturer Guidelines (Spedfy) <br /> E Industry Code or Engineering Standard (Specify) PEI/RP1200 - 1 Z <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.) 508122/Dsl/15k <br /> What is the tank inside diameter? (Inches) <br /> Is the fill piping secondarily contained? ❑ Yes ❑ No E Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes ❑ No ❑ Yes E No ❑ Yes ❑ No ❑ Yes ❑ No <br /> OPW <br /> Overfill Prevention Equipment Manufacturers) <br /> 71 SO <br /> What Is the overfill prevention equipment ❑ Shuts Off Floe E Shuts Off Flow ElShuts Off Flow ❑ Shuts Off Flow <br /> response when activated ? ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> (Check all that apply.) ❑ AIV Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors Installed on vent piping? ❑ Yes ❑ No ❑ Yes E No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level In the tank is the overfill prevention © L j <br /> set to activate? (Inches from bottom of tank) <br /> What Is the percent capacity of the tank at which o <br /> the overfill prevention equipment activates? LA <br /> Is the overfill prevention in proper operating ❑ Yes E Yes LEIN <br /> ❑ Yes <br /> condition to respond when the substance ❑ No ❑ No ❑ No <br /> reaches the appropriate level? (Specify In section V. ) (Specify In section V.) in section V. ) (Specify in section V.) <br /> IV, SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass ❑ Fail E 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 /> APR 12 2019 <br /> nn1541i iT A Is u�- EAP:(--i <br /> nA n7r <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 233 division 30 <br /> chapter 16, section 2637.2 and all the information co nod herein Is accurate. <br /> UST Service Technician Signature <br /> ifthe facility has more components than Ohs m2 accom7hodates, additional copies of this page maybe attached. <br /> CMS = Calii'ornla FaninenmmWRcportWg Sydem4IID = Identificatioi4 USI' =UuduVound btoragetank, ICC = fidmudiumd Code Coumi , A/V =Audible and visual <br />