COMPLIANCE INFO_2010-2018 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑Repair Inspection 9 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181251 8/29/2018 Business Name(Same as Facility Name or DBA-Doing Business As) CANEPAS CAR WASH Business Site Address 3TOCKTON y ZIP Code 6230 PACIFIC AVE CA 95207 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the/CC Certification.) Phone# David Winkler (209) 744-0112 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2 0 Emco #3207 Ex. 09-21-2020 VR: B34975 ATG:2/8/20 xfi .; Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION N Inspection Method ❑x Manufacturer Guidelines(Specify): Used: Removed Drop Tubes N0''' 3 0 x°018 ❑Industry Code or Engineering Standard(Specify): ❑Engineered Method(Specify): I v TM :N.T Attach the inspection procedures and all documentation required to determine the results. 46fAttached Pages 10 TANK ID:(By tank number,stored product,etc.) 87S 87 N 91 DSL What is the tank inside diameter?(Inches) 95.25 95.25 95.25 95.25 Is the fill piping secondarily contained? ❑Yes 0 No ❑Yes 0 No ❑Yes ❑x No ❑Yes ❑x No Is the vent piping secondarily contained? ❑Yes ®No ❑Yes El No ❑Yes [j]No ❑Yes ❑x No Overfill Prevention Equipment Manufacturer(s) oPw oPw OPw EMCO 61-SO 61-SO 61-SO 1100 What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow [E Shuts Off Flow ®Shuts Off Flow when activated? ❑ (Check all that apply.) Restricts Flow El Restricts Flow El Restricts Flow E]Restricts Flow ❑A/V Alarm ❑A/V Alarm ❑AN Alarm ❑A/V Alarm Are flow restrictors installed on vent piping? ❑Yes ❑x No ❑Yes [E No ❑Yes R No ❑Yes ®No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) 8611 8611 8611 64.5„ What is the percent capacity of the tank at which the overfill prevention equipment activates? 95 95 95 72% Is the overfill prevention in proper operating condition ®Yes ❑D Yes El Yes n Yes to respond when the substance reaches the appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ®Pass ❑Fail I ❑x Pass ❑Fail ❑x Pass ❑Fail ❑x 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 equipment was 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=Identficalion,UST=Underground Storage Tank,ICC=International Code Council,AN=Audible and Usual