Laserfiche WebLink
If the facility has more components than this form accommodates, additional copies of this page maybe attached. <br />CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council, AN= <br />UNDERGROUND STORAGE TANK <br />OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) <br />Type of Action ❑ Installation Inspection ❑ Repair Inspection [ 36 Month Inspection <br />I. FACILITY INFORMATION <br />CERS ID <br />10180631 <br />Date of Overfill Prevention Equipment Inspection <br />10/l/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Quik Stop Market #152 <br />Business Site Address <br />1721 S. Cherokee Ln <br />City <br />Lodi <br />ZIP Code <br />95240 <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 />Max Hines, Paul Wright <br />Phone # <br />(209) 369-7375 <br />Contractor / Tank Tester License # <br />617238 <br />ICC Certification # <br />8750053 <br />ICC Certification Expiration Date <br />11/9/2019 <br />Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br />OPW 100565 <br />RECER ,. . <br />III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br />Inspection Method <br />Used: <br />9 Manufacturer Guidelines-(Specify):3 <br />OPW Install & Maintenance Guidelines <br />❑ Industry Code or Engineering Standard (Specify): ENVIRONMENTAL I EALi <br />❑ Engineered Method (Specify): DEPARTMENT <br />Attach the inspection procedures and all documentation required to determine the results. <br /># of Attached Pages <br />TANK ID: (By tank number, storedproduct, etc.) <br />91 <br />Diesel <br />87 <br />What is the tank inside diameter? (Inches) <br />893/4 <br />893/4 <br />893/4 <br />Is the fill piping secondarily contained? <br />Z Yes ❑ No <br />El Yes ❑ No <br />H Yes ❑ No <br />❑ Yes ❑ No <br />Is the vent piping secondarily contained? <br />Z Yes ❑ No <br />2 Yes ❑ No <br />0 Yes ❑ No <br />❑ Yes ❑ No <br />Overfill Prevention Equipment Manufacturer(s) <br />OPW <br />OPW <br />oPw <br />What is the overfill prevention equipment response <br />when activated? <br />(Check all that apply.) <br />❑ Shuts Off Flow <br />E Restricts Flow <br />❑ AIV Alarm <br />❑ Shuts Off Flow <br />❑x Restricts Flow <br />❑ A/V Alarm <br />❑ Shuts Off Flow <br />E Restricts Flow <br />❑ AIV Alarm <br />❑ Shuts Off Flow <br />❑ Restricts Flow <br />❑ AIV Alarm <br />Are flow restrictors installed on vent piping? <br />❑Yes No <br />❑ Yes E No <br />❑ Yes ❑% No <br />❑ Yes ❑ No <br />At what level in the tank is the overfill prevention set <br />to activate? (Inches from bottom of tank.) <br />801/4 <br />801/4 <br />80318 <br />What is the percent capacity of the tank at which the <br />overfill prevention equipment activates? <br />93% <br />86% <br />86% <br />Is the overfill prevention in proper operating condition <br />to respond when the substance reaches the <br />appropriate level? <br />❑x Yes <br />❑ No (Specify in V.) <br />❑x Yes <br />❑ No (Specify in V.) <br />❑x Yes <br />❑ No (Specify in V.) <br />❑ Yes <br />❑ No (Specify in V.) <br />IV. SUMMARY OF INSPECTION <br />RESULTS <br />Overfill Prevention Inspection Results <br />Pass ❑Fail <br />Pass ❑Fail <br />Pass ❑Fail <br />❑ Pass El Fail <br />.119 <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 />hereby certify that the overfill prevention equipmentwas 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 />Audible and Usual <br />