Laserfiche WebLink
8000100111121 <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of i ) <br /> sommummunumm <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection <br /> L FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10181407 9/9/19 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Kwikserve BW 113 <br /> Business Site Address City _ ZIP Code <br /> 420 W Kettieman Ln , Lodi 95240 <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 /> Kristopher Bell (408) 971 -2445 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 485184 8833000 7/22/20 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> 902968 <br /> Ill . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method 0 Manufacturer Guidelines (Specify) : OPW <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 product, etc) 1 -87 Unleaded 2- Diesel 3-91 premium 4- E85 <br /> What is the tank inside diameter? (Inches) 120" 120" 120" 120" <br /> Is the fill piping secondarily contained? ❑ Yes 0 No ❑ Yes 0 No ❑ Yes ® No ❑ Yes O No <br /> Is the vent piping secondarily contained? © Yes ❑ No ❑ Yes ❑ No © Yes ❑ No 0 Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW OPW <br /> 71 SO 71 SO <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow 0 Shuts Off Flow 0 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 restrictors installed on vent piping? ❑ Yes ❑ 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.) 105.625" 105 .625" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 93. 948% 93 . 948% <br /> Is the overfill prevention in proper operating condition ❑ Yes ❑ Yes 0 Yes 0 Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑ No (Specify in V.) ❑ No (Specifyin V) ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑ Pass El Fail ❑ Pass ❑ Fail ® Pass ❑ Fail 0 Pass [I Fall <br /> _._. V. COMMENTS <br /> Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <br /> Wasn't able to removed 87 and Diesel Drop Tubes from tank Direct Bury Spill Buckets . <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 235 <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 = CaKomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual <br />