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MAR 2 1 2019 <br /> i <br /> UNDERGROUND STORAGE TANK _ / . <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPOII� t i � Qt11 � �� <br /> Type of Action installation Inspection ❑ Repair Inspection ❑ 36 Month inspection <br /> 1. FACILITY INFORMATION <br /> aaaiaCERS ID0 ( Date of Overfill Equipment Inspection <br /> 1307 ; 3 <br /> Business Name (Same as Facility Name or, bl[3Aotng B Hess As) <br /> Business Site Address c1J• City Z . Code <br /> 06 a Aet44 .�s qs 0 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION �p <br /> Name of UST Service Tei an Ping )hg _Irrt fes shown on the ICC Certification.) Phone #� it( <br /> (Zovo / '� z 4 fJ <br /> Contractor I Tank Te ucerlse # [COWfification # ne 6 : Q ICC Certification Expiry n at <br /> ( I <br /> ai ao <br /> Overfill Pre; ntion Equipment Inspection Training and Certifi ons (List applicable cer0cations.) <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method iRi Manufacturer Guidelines (Specify): / <br /> Used : 7" ( . "OXOAJS 6W / 190'(2 /G7lD �t/1�1 , <br /> Industry Code or Engineering Standard (Specify): 9q44. t acu <br /> ❑ Engineered Method (Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages <br /> TANK ID : (By tank number, stored product, etc.) <br /> What is the tank Inside diameter? (Inches) <br /> Is the fill piping secondarily contained ? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes <br /> ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained? ❑ Yes ❑ No ❑ Yes <br /> ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) OPW W W <br /> � 0 � <br /> What is the overfill prevention equipment response Shuts Oft Flow Shuts Off Flow ® Shuts Oft Flow ❑ Shuts Off Flow <br /> when activated? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑ ArV Alarm ❑ AIV Alarm ❑ AIV Alarm ❑ AIV Alarm <br /> Are flow restrictors installed on vent piping? ❑ Yes PNo <br /> [:1 Yes �allo [I Yes Q No ❑ Yes ❑ No <br /> At what level In the tank is the overfill prevention set I <br /> „ <br /> to activate? (Inches from bottom of tank.) 63 / v <br /> What is the percent capacity of the tank at which the I / Q�ll <br /> overfill prevention equipment activates? ( � ! 7 t <br /> Is the overfill prevention In proper operating condition pyes Yes , Yes ❑ Yes <br /> to respond when the substance reaches the Y' <br /> appropriate level? 1 ❑ No (Specify In V) ❑ No (Specify in V.) I ❑ No (Specify in V.) ❑ No (Specify in V.) <br /> IV, SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results rwPass ❑ Feil Pass ❑ Fail Pass ❑ Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked `Fall” 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 equipment was Inspected in accordance with California Code of Regulations, Title 23 , <br /> Division 3, Chapter 16, Section 2637. 2 and all the 1 atlon contained herein Is accurate. <br /> UST Service Technician Signature <br /> if the lacilltyhes more components than this form accommodates, add/ld pnpr :oples of this page maybe attached. <br /> CERS = Caffornia Envlroi r>ial Reporting System, ID = Idarttilicatlon, UST = Undergrurtxi Storage Ta* ICC = international Code Count, AN = Aube and VvA <br />