Laserfiche WebLink
Ll <br />E <br />tADERGROUNDSTORAGETANK <br />S E P 2 8C�AkFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of i) <br />i — <br />i: Type of Action Installation Inspection C] Repair inspection 2136 Month inspection <br />L rll=/ALI r"I <br />L 1. FACILITY INFORMATION <br />mDEPXr�Qfll E NT <br />I Date of Overfill Prevention Equipment Inspection <br />9/24/2018 <br />I Business Name (Same as Facility Na me or DBA -Doing Business As) <br />Quik Stop #121 <br />Business Site Address <br />1196 W. Louise Ave <br />Manteca <br />ZIP Code <br />95336 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of LIST Service Technician Performing '�he Inspection (Print as shown on the ICC Certification.) <br />Juan Jauregui <br />Phone <br />(9 i',: 889-3897 <br />Contractor I Tank Tester License <br />OverfillPrevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />Phase100580 <br />Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />9 Manufacturer Guidelines (Specify): <br />[3 Industry Code or Engineering Standard (Specify): <br />[3 Engineered Method (Specify): <br />Attach the inspection procedures and all documentation required to determine the results. <br />�79AKID: (By tank number, stored product, <br />Gasoline - 91 <br />7WFat is the tank inside diameter? (inches) <br />Is the fill piping secondarily contained? <br />--- ------------------ <br />s the.vent piping secondarily contained? <br />#veffiTl­Pr­ev­e­n1ion Equipment Manufacturer(s) <br />when activated? <br />(Check all that apply.) <br />[I Shuts Off Flow <br />Rx Restricts Flow <br />0 AN L yr <br />n Shuts If <br />stricts Flow <br />X•El <br />i y Alarm <br />Shuts Off Flow <br />Restricts Flow <br />0 AN Alarm <br />i,[ C] Shuts Off Flow <br />Restricts Flow <br />AN Alarm <br />Are flow restrictors; installed on vent piping? <br />r_1 Yes <br />to activate? (Inches from bottom of tank.) <br />V <br />0 erfill prevention equipment activates? <br />is Ine overfill prevention in proper operating cMipp <br />ondition l�, <br />t■ <br />o respond when the substance reaches the 11 <br />j!pp,opriate level? <br />E] yes <br />9 No (Specifv in V.) <br />10 <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />V. COMMENTS <br />Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. <br />A. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br />I I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations, e <br />1 Division 3, Chapter 16, Section 2 7.2 and all the information contained herein is accurate. <br />LIST Service To, <br />Guarnmoua s, a r lonarMFID3-0-Y -rs page may be attached. <br />CERS = California Reporting ID = Identification, UST = Underground Storage Tank, ICC = International Code Cm -d, AIV = ALdiblee and VGual <br />