Laserfiche WebLink
' 1 <br /> I <br /> i <br /> UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection 0 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 101868637 8/ 19/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> MANTECA GAS AND FOOD <br /> Business Site Address City ZIP Code <br /> 1229 E LOUISE MANTECA 95336 <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 /> Felix Ramirez 1 (209) 744-0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08- 1740 Ex. 03/31 /2020 8883072-UT 11 /9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- FF- EBW , PhikTite & EVR Phase 1 1009883708 EX 11 -29-20 OPW 104 -634 Ex 3 - 14-2020 <br /> Emco 3147 Ex. 11A &20 VR : B34976 ATG : 7/7/20 Incon 1009883708 Ex 11 -30-20 <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : <br /> Used : PROBES <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 3 <br /> TANK ID : (By tank number, stored product, etc.) 87 91 DIESEL <br /> What is the tank inside diameter? (Inches) 96 96 96 <br /> Is the fill piping secondarily contained? ❑X Yes ❑ No HI Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑x Yes ❑ No ❑x Yes ❑ No I] Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) VEEDER VEEDER VEEDER <br /> ROOT ROOT ROOT <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) El Restricts Flow ❑ Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑Q AN Alarm ❑D AN Alarm ❑Q AIV Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes E No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br /> to activate? (Inches from bottom of tank.) 80 80 80 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 89 % 89 % 89 % <br /> Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes ❑x 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 IE Pass ❑ Fail I ❑x Pass it ❑x 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 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 /> 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 = Audible and Usual <br />