COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

%I M1 G� UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (RF-cope1 ,ofll ) . ) ? i` Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection I . FACILITY INFORMATION F Vii ; sx ; i ; r N 1" C ' A ' T CERS ID Date of Overfill PreuorltioN Equipmpnt Inspection 10180905 1 '0/27018 ' ' Business Name (Same as Facility Name or DBA-Doing Business As) JD SINGH - PACIFIC SERVICE STATION Business Site Address City ZIP Code 6131 PACIFIC AVE ISTOCKTON , CA 95207 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Edward Stearns (209 ) 744-0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 14- 1760 Ex . 09/30/2020 8883080-UT 11 /8/2018 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , PhikTite & EVR Phase 1 1009893708 Ex 11 / 16/ 18 OPW 104-635 Ex 3- 14-2020 Emco Ex . 10- 1 -20 VR A31048 Ex . 8/9/ 19 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : REMOVED DROP TUBES a INSPECTED Used : ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages TANK ID : (By tank number, stored product, etc.) 87 91 D I E What is the tank inside diameter? (Inches) 92 92 if 92 " Is the fill piping secondarily contained ? ❑ Yes [] No ❑ Yes EINo ❑ Yes 2 No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes n No ❑ Yes 0 No ❑ Yes E] No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW 6150 6150 6150 What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? ❑x Restricts Flow X Restricts Flow 0 Restricts Flow ❑ Restricts Flow (Check all that apply) ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? ❑ Yes Z No ❑ Yes N No ❑ Yes R No ❑ Yes ❑ No At what level in the tank is the overfill prevention set if to activate? (Inches from bottom of tank.) 84 87 . 2 " 86 . 4 " What is the percent capacity of the tank at which the overfill prevention equipment activates? 92 % 95 % 94 % Is the overfill prevention in proper operating condition ❑x Yes 0 Yes 0 Yes ❑ Yes to respond when the substance reaches the y in V.) El (Specify in V.) El (Specify in V.) El (Specify in V.) appropriate level? El No (Specif IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results Pass ❑ Fail ❑x Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here . VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23, Division 3 , Chapter 16, Section 2637.2 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, AN = Audible and Usual