COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181241 9/ 19/2018 Business Name (Same as Facility Name or DBA-Doing Business As) PARKWOOD SHELL Business Site Address city ZIP Code 1612 W Hammer Lane Stockton 95209 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Zane Nimmo (209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 04- 1676 Ex . 03/31 /2019 8883064- UT 6/ 1 /2019 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , PhikTite & EVR Phase 1 10009843708 Ex 11 -29 -20 OPW 104-632 Ex 3- 14-2020 Emco 3206 Ex . 11 / 14/2020 ATG : VR : A28446 Ex . 9/28/ 19 Incon # 1009843708 Ex . 11 -30-20 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : OPW Used : ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 5 TANK ID : (By tank number, storedproduct, etc.) 1 - DIESEL 87 91 What is the tank inside diameter? (Inches) 96 96 96 Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes E No Is the vent piping secondarily contained ? ❑ Yes [j] No ❑ Yes N No ❑ Yes M No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) VEEDER ROOT What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow ❑x Shuts Off Flow ❑ Shuts Off Flow when activated ? ❑ (Check all that apply.) Restricts Flow ❑ Restricts Flow El Restricts Flow El Restricts Flow E A/V Alarm E A/V Alarm ❑ AIV Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping ? ❑ Yes ❑x No ❑ Yes ❑X No ❑ Yes 0 No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank.) 97 86 86 . 25 What is the percent capacity of the tank at which the overfill prevention equipment activates? 101 94 % 95 % Is the overfill prevention in proper operating condition ❑ Yes ❑x Yes ❑x Yes ❑ Yes to respond when the substance reaches the appropriate level ? ❑x No (Specify in V. ❑ No (Specify in V.) ❑ No (Specify in V) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑ Pass MT il 0 Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS In 7 1 , Any items marked "Fail" must be explained in this section . Any additional comments may also be ided here. MAII 2 5 2019 Vi . CERTIFICATION BY UST SERVICE TECHNICIAN CON DUCTIN r.IN4, R ( TIQN\ HEALT�-} I hereby certify that the overfill prevention equipment was inspected in accordance with California Co g1:of-Regulatipnsjitle 23, Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AA/ = Audible and Visual