Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br /> Type of Action ❑Installation Inspection ❑Repair Inspection 9 36 Month Inspection <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10397599 10/3/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Sutter Tracy Hospital <br /> Business Site Address City ZIP Code <br /> 1420 N. Tracy Blvd. Tracy 95376 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> David Winkler (209) 744-0112 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 08-1739 Ex.3/31/2020 8883059-UT 1/29/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW , Phil-Tite &EVR Phase 1 1009853708 Ex 11-16-18 OPW 104-633 Ex 3-14-2020 <br /> Emco Ex. 10-1-20 VR: B34975 ATG: 2/8/20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION 1 <br /> Inspection Method ®Manufacturer Guidelines(Specify): <br /> Used: Removed Drop Tube §, I <br /> NMI i <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): ENVIRONMENT/\L, HEALTH <br /> Attach the inspection procedures and all documentation required to determine the results. #bi xtsachen.. WA <br /> TANK ID:(By tank number,stored product,etc.) DSL <br /> What is the tank inside diameter?(Inches) 96 <br /> Is the fill piping secondarily contained? ❑Yes ®No ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑ No <br /> Is the vent piping secondarily contained? ❑Yes ®No ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) Emco <br /> A1100 <br /> What is the overfill prevention equipment response I ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> when activated? ❑x Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> (Check all that apply.) <br /> ❑A/V Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes [E No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention set <br /> to activate?(Inches from bottom of tank.) 80 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 89% <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑Yes ❑Yes ❑Yes <br /> to respond when the substance reaches the <br /> appropriate level? ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) ❑No(Specify in V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑Fail I ❑Pass ❑Fail 11 ❑Pass ❑Fail ❑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 <br /> If the facility has more components than this form accommodates,additional copies of this page may be attached. <br /> CERS=Catifomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,AIV=Audible and Visual <br />