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E V'r <br /> 1 1 .. <br /> NOV C 7 2018 <br /> EN R�NME UNDERGROUND STORAGE TANK <br /> )F.F RTME RFILL 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 Date of Overfill Prevention Equipment Inspection <br /> to 1511 -Z5 <br /> Business Name(Same as Facility Name or DBA-Doing Business As.) <br /> S r--1 S fock-i-o-t <br /> t3us1 ess Site Address, d ty ZIP Code <br /> CPnDv Avg cS fvcl� crszoq <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection(Print as shown on the(CC Certification.) Phone# <br /> O 7 N OS E,d_ <br /> Contractorlrank Tester Lice se# ICC Certification# ICC Certification Expiration Date <br /> 7v�z3 195Z27 6- Z-2-0Iq <br /> Overfill Preve ion Equip ir14JS�r ion Training and Certifications(List applicable certifications.) <br /> `7 III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method Used: $Manufacturer Guidelines(Specify) <br /> 19 Industry Code or Engineering Standard(Specify) PFT 172QO <br /> ❑Engineered Method(Specify) <br /> Attach the inspection procedures and afl documentation required to determine the results. #of Attached Pages: <br /> Tank ID:(By tank number:stored product,etc.) D 4,sd <br /> What is the tank inside diameter?(inches) <br /> Is the fill piping secondarily contained? ❑Yes ]$No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes grNo ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> 0^j <br /> Overfill Prevention Equipment Manufacturer(s) Jur <br /> What is the overfill prevention equipment ($Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow <br /> response when activated? ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑Restricts Flow <br /> t <br /> (Check all that apply.) <br /> I gAN Alarm ❑AN Alarm ❑A/V Alarm ❑AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes $Q No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> At what level in the tank is the overfill prevention 7S rf <br /> set to activate?(Inches from bottom of tank.) <br /> What is the percent capacity of the tank at which Cl O <br /> the overfill prevention equipment activates? 1 <br /> Is the overfill prevention in proper operating ,M Yes ❑Yes ❑Yes ❑Yes <br /> condition to respond when the substance []No ❑No ❑No ❑No <br /> reaches the appropriate level? (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 Inspection Results *�R Pass ❑Fail I ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail <br /> V. COMMENTS <br /> All 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 /> 1 hereby certify that the overfill prevention equipment was inspected In accordance with California Code of Regulations,title 23,division 3. <br /> chapter 16,section 2637.2 and all the i Tatiqrtcontaiined herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more compo nts tha his fo accommodates,additional copies of this page may be attached. <br /> CERS=California Environmental Reporff ystem,ID=1dentiflcation,UST=Underground storage tank,ICC=International code Council.A(V-Audible and visual <br />