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t • UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTIONREPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑Repair Inspection ®36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10643278 10/11/2018 Business Name(Same as Facility Name or DBA-Doing Business As.) San Joaquin General Hospital Business Site Address City ZIP Code 500 W. Hospital Rd French Cam 95231 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# Eric Mol aard 209 367-4800 Ext. Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 774802 8881020 02/25/2019 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) 111. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: ❑Manufacturer Guidelines(Specify) ® Industry Code or Engineering Standard(Specify)PEI/RP1200-17 ❑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.) RED DIE What is the tank inside diameter?(Inches) 91 Is the fill piping secondarily contained? ID Yes ❑No ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No OPW Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment ®Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow (Check all that apply.) ®AN Alarm ❑AN Alarm ❑A/V Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ❑Yes ® No ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑No At what level in the tank is the overfill prevention 81 set to activate?(Inches from bottom of tank.) What is the percent capacity of the tank at which 95 the overfill prevention equipment activates? Is the overfill prevention in proper operating ®Yes ❑Yes ❑Yes ❑Yes condition to respond when the substance ❑No ❑ No ❑No ❑No reaches the appropriate level? (Specify in section V.) (Specify in section V.) pecify'n section V.) (Specify in section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ®Pass 0 Fail 11 ❑ Pass ❑Fail ❑Pass ❑Fail I ❑ Pass ❑ Fail V. COMMENTS All items marked"Fail'must be explained in this section. Any additional comments may also be provided here. �,z� Tank level and percentage is based on the 'Shuts Off Flow' method .Y Tank level with the AN Alarm is set at 76" and the percentage is 90%. Alarm p I JkL- 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 Signatu If the facility has more comp an this form accommodates,additional copies of this page may be attached. CERS=California Environmental Retorting System,fD=Identification,UST=Underground storage tank,ICC=International Code CoundiL AN=Audible and visual