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R E G,-yY3 ' IE-00 <br /> DEC P 5 2018 <br /> UNDERGROUND STORAGE TANK rr�t`/IRON "7NTAL HE TH <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORAM( Alf 1) .-rR `mNIT <br /> Type of Action Installation Inspection ❑Repair Inspection ❑36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Dete of Overfill Prevention Equipment Inspection <br /> )b1,11 z(,3 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> A <br /> Business Site Address City ZIP Code <br /> SS w i pff S33 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certificadon.) Phone# <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 2--Lo-03 jR o1 -77SS 7I-71t1 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> Q(°tr-� OvcfA�ilk r�Ucw� on <br /> 1,V. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> inspection Method Wmanufacturer Guidelines(Specify): <br /> Used: <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation #of Attached Pages <br /> pe p required to determine the results. <br /> TANK 10:(By tank number,stored product,etc.) k <br /> What is the tank inside diameter?(inches) ,lg• 2 `t 4 •L 1iq �� <br /> Is the fill piping secondarily contained? Yes ❑No VYes <br /> ❑No es ❑No [3 Yes ❑No <br /> Is the vent piping secondarily contained? 'Yes ❑No es ❑No es ❑NoYes <br /> ❑ ❑No <br /> Overfill Prevention Equipment Manufacturer(s) � w <br /> What is the overfill prevention equipment response irshuts Off Flow huts Off Flow Shuts Off Flow ❑Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restncts Flow <br /> ❑A/V Alarm ❑A/V Alarm ❑A/V Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes ErNo ❑Yes No <br /> ❑Yes M<o C1 Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(inches from bottom of tank.) I04.11,�' (tY3.S Ida.Zs <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? C(—&"to �t3d(v C1 <br /> Is the overfill prevention in proper operating condition yes Yes Yas ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) I ❑No(Specify in V.) ❑No(Specify in V. ❑No(Specify in V.) <br /> IV. SIiJMMARY OF INSP TION RESULTS <br /> Overfill Prevention Inspection Results V Pass ❑Fail I N Pass ❑Fell I WPass <br /> ❑Fall ❑Pass El Fail <br /> V. COMMENTS <br /> Any items marked"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 that the overfill prevention equipment was inspected In accordance with California Code of Regulations,Title 23, <br /> Division 3,Chapter 16,Section 637.2 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more compo otffmadatas,additional copies of this page may be attached. <br /> CERS=California Environmental Reporting System,ID=klertlCation,UST=Underground Storage Tank,ICC=Irdemational Code Courxii,AIV=Audible and Visual <br />