Laserfiche WebLink
UNDERGROUND STORAGE TANK <br />„ u,a ,acu,ty nas more components than tms rorm accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />10181267 7 <br />Date of Overfill Prevention Equipment Inspection <br />10/5/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />CALIFORNIA NATIONAL GUARD - STOCKTON AIRPORT <br />Business Site Address <br />City <br />ZIP Code <br />2000 STINSON RD, <br />STOCKTON, CA <br />95206 <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 />Phone # <br />FELIX RAMIREZ <br />(209) 744-0112 <br />Contractor / Tank Tester License # <br />ICC Certification # <br />ICC Certification Expiration Date <br />08-1740 5-31-18 <br />8883072 -UT <br />11/22/2018 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />OPW 104634 3-14-20 <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />❑x Manufacturer Guidelines (Specify): <br />Used: <br />OPW <br />❑ Industry Code or, Engineering Standard (Specify): <br />❑ Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, stored product, etc.) <br />AV Gas <br />What is the tank inside diameter? (Inches) <br />128 <br />Is the fill piping secondarily contained? <br />❑ Yes[j] No <br />El Yes ❑ No <br />EJ Yes ❑ No <br />❑Yes ❑ No <br />Is the vent piping secondarily contained? <br />❑ Yes El No <br />❑ Yes ❑ No <br />El Yes ❑ No <br />El Yes ❑ No <br />Overfill Prevention Equipment ManufactureP(s) <br />OPW <br />What is the overfill prevention equipment response <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />❑ Shuts Off Flow <br />when activated? <br />(Check all that apply.) <br />[] Restricts Flow <br />❑ Restricts Flow <br />❑ Restricts Flow <br />❑ Restricts Flow <br />❑ A/V Alarm <br />❑ A/V Alarm <br />❑ A/V Alarm <br />❑ A/V Alarm <br />Are flow restrictors installed on vent piping? <br />❑ Yes N No <br />❑Yes ❑ No <br />I El Yes ❑ No <br />El Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />115 <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />90% <br />Is the overfill prevention in proper operating condition <br />❑x Yes <br />❑ Yes <br />❑ Yes <br />❑ Yes <br />to respond when the substance reaches the <br />appropriate level? <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />❑x Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑Pass ❑Fail <br />❑ 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 equipment was 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,; lr <br />Code Council, AN =Audible and Visual <br />