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.# NW1-2337835 Cust ® COCO SO-0015267473 <br /> 11010 <br /> UNDERGROUNDSTORAGETANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT F (page i at i) <br /> ! Type of Action ®177-ltaWn Ins ctirxt D P,, r ins non <br /> .pay ... 16 h4onth inspection <br /> (. FACILITY INFORMATION 4 ---_ <br /> I CEPS Its <br /> Date at Ckrerf A Prpventq n Etluspment Prset >n1 <br /> I BustreSs Pianpe(Sema as Facrtety fume ur GY11A-®oupgy Susrrsass As) <br /> Tr ,. _ <br /> ! Bv4irse$$Sit®Address ..:ty ZIP Code <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION — <br /> Nattte 0-T01- Strrtt;C Tee 's:.^can Fer'CHmtr ti's M?SpeCtdOn f"",As ShETNyt bra Phe ICC t;er%r!;ralKx`, i Phone a <br /> t a s <br /> Contractor i Tang Tester(?cense a IC Gentfcatzor a ICC..omilrat,a�Exanratu>n Date — <br /> aN-erm Prevention EdiiPrnent lns eecmn Train"and Cartrf cs ttonsl r0st ap eabie <br /> st P ' i J d <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> inspeet c r U od anufacturer Guidelines IS ly1 <br /> Used <br /> � <br /> 0 Industry Cone or EngaPetrerzrag Stanratd tSpaertyt <br /> - , ®Engineered kiethold fspocof <br /> Attach the ins tlon u and all documentation required to determine the results. i act Anached Paws <br /> TANK 10:(By Renk nernber.stared <br /> = What a the tank onside diameter?(ireefras) i ysy <br /> IS IPee tar .—.--._— _._....._ <br /> �p�seeo�ardYccaastar,et7o <br /> ®Yes g kc .. Yet <br /> ,Q R c Q res [Into ©vas G No <br /> Is are vent p+prnq s®cohaaniy tt r to naea7 ®Yes 'No (^vas �'No G Yes G No C7 yes �;No <br /> CDverlt4CPrevenbonEQuepmer.114ianutari�rretlsC <br /> Wluli G the rverP,U prevenlcon etl.ilp nt rare, se Hots cYf Flow Q Shuts Dt!Flow F SPUS Off Plow C]Shuts Oft Flow <br /> 'hen achvateV <br /> (Check all that apply t Q Rant, s Flo,* 0 Resinr„ts Frew [I Restnos Fi0 p Rastr:c!s Flaw <br /> E)A'V 'tiami L:]AN Alam++ L7 A,%,Aar- 0 AV Aiko <br /> Are flaw restrictons fr sterred on vent Pepr<e9' ®"ras [3 <br /> �-__ -----__ ._ [I hr. [I t es C1 Nc [I Yes [I No t:"°e3 Nc <br /> Al weld level:r tate lank is Ilw overhI prove"ann set <br /> to activate')(Inches from b000m of rank J <br /> What is tree percent capaetty oaf(Pse tank at vrhaGtt the <br /> overfill prevent on equipment activates? <br /> ' .r._.._— <br /> Is the r€i€t iueventarrs rn prnGee a€aGrsp candlaf t `Yes Yes [I Yes . Qv es <br /> to respond when the substancka reaches the <br /> aPMoRstsafs GsveP'p [I <br /> No t,BCi en�.I ''��. Pao(:SdTacd; V J [I Pea iecdy azs Y.1 (�Ivo{Sp 'Py rn Y-t <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> tOverfill Prevention Inspectrori Results 'PasP ®Fad 6&Pass i[I Fail [I pass F&I ❑Pass ©Fal <br /> V. COMMENTS <br /> Any..--.—_—_.�_,.._. ............. _. _...___._. _._.._.._. 1 <br /> Any items mark `Fel€ must he explamed,in t4 Iron Any dd*nral comments may also be Provided here <br /> 3 <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION – <br /> 1 hereby certify that the overfill prevention equipment was ins .ted in accordance with California Code of Re®utati s,Title 23, <br /> Division 3,Chapter 16,Section 2637.2 and all the information contained herein is accurate. <br /> t!firer hes mak:c aignau:ce <br /> Ponents than t Is form lei; amrapdates, !Ilona/Caples Of this Pag_ e may.. attached, <br /> CERS=Caborm Eirtartivneru Repaurg Swor 0 uST W,indervarm SolrageTars,K:,C A,: y <br /> RECF ' iE0 <br /> Overfill inspection report )CT 1, 6 2018 <br /> ENVIRONMENTL HEALTH <br /> DEpApTMENT <br />