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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of t) <br /> Type of Action ❑ Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection <br /> 1. FACILITY INFORMATION <br /> CERS ID 10181003 Date of Overfill Prevention Equipment Inspection <br /> 2/13/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> DAMERON HOSPITAL <br /> Business Site Address City ZIP Code <br /> 525 W. ACACIA STREET STOCKTON 95203 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Ceitifcation.) Phone# <br /> Zane Nimmo (209) 744-0112 <br /> Contractor/Tank Tester License# ---FICC—Certification Certification# ICC Certification Expiration Date <br /> 04-1676 Ex.03/31/2019 8883064-UT 6/1/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW, Phil-Tite &EVR Phase 1 10009843708 Ex 11-29-20 OPW 104-632 Ex <br /> Emco 3206 Ex. 11/14/2020 ATG: VR: A28446 Ex. 9/28/19 Incon#1009843708 Ex.1vfcnPR�, <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION IN O <br /> Inspection Method ❑X Manufacturer Guidelines(Specify): <br /> Used: O P W 'LIAR � 12019 <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): ENIVIRONMENTAL <br /> DEPARTMENT <br /> Attach the inspection procedures and alt documentation required to determine the results. #of Attached Pages 3 <br /> TANK ID: (By tank number,storedproduct,etc.) 1 - DIESEL <br /> What is the tank inside diameter?(Inches) 95.0 <br /> Is the fill piping secondarily contained? ❑Yes El No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes ❑• No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) oaW <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 /> (Check all that apply.) ❑ Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow reslrictors installed on vent piping? ❑Yes Z 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.) 82.5' <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 92% <br /> Is the overfill prevention in proper operating condition Zx Yes ❑Yes ❑Yes ❑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(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results 9 Pass ❑Fail ❑ Pass ❑Fail ❑Pass ❑Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items markod'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 thatthe 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 this form accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Coundl,AN=Audible and Visual <br />