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:.1EC.7EINED <br /> DEI 1 U 2018 <br /> AL HEALi t <br /> UNDERGROUND STORAGE TANKP. <br /> AFdTMENT <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(Page 1 at 1) <br /> Type of Action 50Installation inspection ❑Repair Inspection ❑36 Month Inspection <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> of( <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> A. ass Site Address City ZIP Code <br /> gSzz <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 /> Contractor f Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1-1 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> 1 <br /> t- <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 Inspect/on procedures and all documentation required to determine the results. #of Attached Pages <br /> i <br /> TANK ID:(By tank number, stored product,etc.) <br /> What is the tank inside diameter?(inches) N1 03 <br /> Is the fill piping secondarily contained? Yes ❑No Yes ❑No SYes ❑No XYes ❑No <br /> Is the vent piping secondarily contained? (�Yes ❑No 14 Yes ❑No gLYes0 No Yes ❑ <br /> No <br /> Overfill Prevention Equipment Manufacturer(s) <br /> What is the overfill prevention equipment response Shuts OH Flow Shuts OH Flow Shuts Off Flow Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑AN Alarm ❑A/V Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes No ❑Yes 5,No <br /> ❑Yes 5jNo ❑Yes PNo <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 107.-'15 5 ICI 4'5 t 25 <br /> What Is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 3 q 30 O13 O(O 0130 <br /> Is the overfill prevention in proper operating condition Yes Yes Yes JJ Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specffy in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results Pass ❑Fail I KPass ❑Fail I VPass ❑Fail 2 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 /> V1. 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 herein is accurate. <br /> UST Servi ician Si re <br /> N the facility has mbfe componerlis then this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Win.UST=Underground Storage Tank,ICC=Intema6orral Cade Cauu3,AN=Audble and Vsual <br />