Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection W1 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />10181229 <br />Date of Overfill Prevention Equipment Inspection <br />11/22120 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Speedway 4873 <br />Business Site Address <br />35 N. Cherokee Ln. <br />City <br />Lodi <br />ZIP Code <br />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.) <br />Kristopher Bell <br />Phone # <br />1(408) 971-2445 <br />Contractor / Tank Tester License # <br />485184 <br />ICC Certification # <br />18833000 <br />ICC Certification Expiration Date <br />7/22/20 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />F. F. #1004933708 <br />OPW # 902968 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />Manufacturer Guidelines (Specify): OPW 61 SO & OPW 71 SO <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 3 <br />TANK ID: (By tank number, stored product, etc.) <br />1 -Regular <br />2- Premium <br />3- Diesel <br />What is the tank inside diameter? (Inches) <br />96" <br />96" <br />96" <br />Is the fill piping secondarily contained? <br />❑ Yes I] No <br />❑ Yes m No <br />❑ Yes la No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes ® No <br />❑ Yes ® No <br />❑ Yes W]No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW <br />OPW <br />OPW <br />61SO <br />71SO <br />7150 <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />la Shuts Off Flow <br />❑Restricts Flow <br />❑ AN Alarm <br />m Shuts Off Flow <br />❑Restricts Flow <br />❑ AN Alarm <br />0 Shuts Off Flow <br />❑Restricts Flow <br />❑ AN Alarm <br />❑ Shuts Off Flow <br />El Restricts Flow <br />❑ AN Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes 0 No <br />❑ Yes m No <br />❑ Yes IZ No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (inches from bottom of tank.) <br />84.50" <br />85.75" <br />84.25" <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />93.65% <br />94.61% <br />93.43% <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />® Yes <br />❑ No (Specify in V.) <br />0 Yes <br />❑ No (Specify in V.) I <br />QI Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results m Pass ❑ Fail 10 Pass ❑ Fail Pass ❑ Fail []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 />VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I hereby certify that the 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 �t4a2e <br />If the facility has more components than this form accommodates, additional copies of this page may be attached. <br />CERS = California Environrrtertal Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemafic n it Code Courtd, AIV = Audible and Vsual <br />