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 1 . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10181355 10/ 11 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) Tiwana Gas & Food Business Site Address City ZIP Code 1210 E Hammer Lane Stockton 95210 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification) Phone # David Winkler (209 ) 744 - 0112 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 08- 1739 Ex. 3/31 /2020 8883059- UT 1 /29/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) FF- EBW , Phil-Tite & EVR Phase 1 1009853708 Ex 11 - 16- 18 OPW 104-633 Ex 3- 14-2020 Emco #3207 Ex . 09-21 -2020 VR : B34975 ATG : 2/8/20 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Used : VR Probes ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify) : Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 TANK ID : (By tank number, stored product, etc.) 87 89 91 What is the tank inside diameter? (Inches) 127 . 5 127 . 5 127 . 5 Is the fill piping secondarily contained ? ❑x Yes ❑ No x❑ Yes ❑ No 0 Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained ? ❑ Yes ❑x No ❑ Yes ❑x No ❑ Yes i] No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) VR VR VR What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated? ❑ (Check all that apply.) Restricts Flow ❑ Restricts Flow El Restricts Flow ❑ Restricts Flow ❑x A/V Alarm Z A/V Alarm Q AIV Alarm ❑ AIV Alarm Are flow restrictors installed on vent piping ? i] Yes ❑ No 0 Yes ❑ No ❑x Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set to activate? (Inches from bottom of tank) 108 . 5 107 . 5 107 . 5 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 90 90 Is the overfill prevention in proper operating condition ❑x Yes (] Yes ZYes El Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V) El No (Specify in V.) El No (Specify in V.) El No (Specify in V) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑x Pass ❑ Fail Q Pass ❑ Fail ❑x Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail' must be explained in this section. Any additional comments may also be provided here. REE V E. D VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING TWf ASPE'OnON I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23, Division 3, Chapter 16, Section 2637. 2 and all the information contained herein is ae _ UST Service Technician Signature � --� DEPARTMENT 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, AN = Audible and Visual