Laserfiche WebLink
UN;�ERGROUN13T70RAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM(PS90 I Of 1) <br /> Type of Action 0 Installation Inspection 0 Repair inspection 36 month inspection <br /> CERS,ID 1.FACILITY INFORMATION Date of overfill Prevention Equipment Inspection <br /> 10156057 10-10-2M <br /> Business Name(So no as Facft Name or DBA-Doing Business As.) <br /> UPS <br /> Business Site city a <br /> 1532 North Broadwa Stockton 95205 <br /> Xdi—m ss <br /> _y <br /> 111. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> -Rime of UST SoM a Technician Performing the inspection(Print as shown on the ICC CermicatIon) Phone# <br /> David Pereira 1 (510)8$9-090 Ext. <br /> Contractorrrank Tei ter License 0 ICC Certification# ICC Certification Expiration Date <br /> 415807 1 5240739-UT 05-21-2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(Ust eApMcable ceitilkeffom) <br /> am 1005513 — <br /> Ill. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> InspectionMethodtised: M manuftwrarGuldeNnes(Specify)012W - <br /> 0 industry Code or Engineering Standard(Specify) <br /> [:1 Engineered Method(Specify) <br /> Attach the Inspecdon procedwas and aN documentation required to determine the resuft #of Attached Pages: <br /> Tank ID:(By tank n,imber,stored product,etc.) T-1 Diesel <br /> What is the tank ins do diameter?(inches) 92 <br /> Is the fill piping secondarily contained? Yes ®No [:1 Yes [3 No 0 Yes 0 No [I Yes [I No <br /> 0 Yes <br /> Is the vent pipings condadly contained? 0 Yes 0 No D Yes [I No [3 Yes [I No D Yes El No <br /> OPW <br /> Overfill Prevention I Equipment Manufacturer(s) <br /> 61so <br /> What is the overfill 1 irevention equipment 0 Shuts ON Flow ❑Shuts Off Flow 0 Shuts Off Flow 0 Shuts Off Flow <br /> response when act!icited? D Restricts Flow ❑Restricts Flow 0 Restricts Flow El Restricts Flow <br /> (Check all that appi.(-) 0 AN Alarm ❑AN Alarm 0 AN Alarm [I AN Alarm <br /> Are flow restrictors; nstalled on vent piping? 0 Yes 10 No ❑Yes [j No 0 Yes 0 NO 0 Yes ❑No <br /> At what level in the ank is the overfill prevention 82 <br /> set to activate?(fix *s from bottom of tank.) <br /> What is the percent, capacity of the tank at which <br /> the overfill preventi in equipment activates? 95 <br /> Is the overfill preve tion In proper operating C9 Yes ❑Yes 0 Yes 0 Yes <br /> ve " <br /> condition to respo when the substance 0 No 10 No 1771 NO 0 No <br /> reaches the app i is Wiel? I (Specify In section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention tlisvpection Results ECg Pan [I Fall 1 0 Pass 1:11 =Fail 0 Pass [3 Fail <br /> V. COMMENTS <br /> AN items marked 7 BiP must be&AP1610011 in this section. Any addlitlonst comments may aisobe�provided ileniK t <br /> N1 nV 0 6 !018 <br /> ionNIKAP TAi-+1EA0F1 <br /> In. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify*A the overfill prevention equipment was Inspected in accordance with Calfforinta Code of Regulations,dtle 23,division 3. <br /> chapter 16,sectk n 2637.2 and all ation contained herein Is accurate. <br /> LIST Service Tech 0clan Signature <br /> tithe facMty has "am conWommite jh*-ffW215hn accommodshm addftkwW copies of yjis page may be aftwJwd. <br /> CERS=CWromileFlnonmertal Reporting Systerm K)-kW"Wda§M LjIST-UndiagaundstmIgstard;IOC=11himnational Code Councit,AN-Audbe andvisual <br />