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PEVRP1200 - 17 USTOVERFILL EQUIPMENTiNSPECTION AUTOMATIC + DEVICE AND BALL FLOAT Facility Name: Owner: Address : Address: "! City, State, Zip Code : City, State , Zip Code: Facility I .D. #: Phone #: Testing Company: Phone #: Date: This data sheet is for inspecting automatic shutoff devices and ball float valves. See PEVRP1200 Section 7 for inspection procedures. Product Grade Tank Number . Tank Volume, gallons Tank Diameter, inches Overfill Prevention Device Brand Type ❑ Automatic ❑ Automatic ❑ Automatic ❑ Automatic ❑ Automatic ❑ Automatic Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device ❑ Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float ❑ Ball Float Valve Valve Valve Valve Valve Valve AUTOMATIC SHUTOFF DEVICE INSPECTION 1. Drop tube removed from tank? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 2. Drop tube and float mecha- ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No nisms free of debris? 3. Float moves freely without binding and poppet moves into ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No flow path? 4. Bypass valve in the drop tube ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No [] Yes ❑ No open and free of blockage (if ❑ Not Present ❑ Not Present ❑ Not Present ❑ Not Present ❑ Not Present ❑ Not Present present)? 5. Flapper adjusted to shut off ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No flow at 95% capacity? * A "No" to any item in Lines 1-5 indicates a test failure. BALL FLOAT VALVE INSPECTION * * 1. Tank top fittings vapor- tight ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No and leakfree? 2. Ball float cage free of debris? ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 3 . Ball free of holes and cracks ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No and moves freely in cage? 4.Vent hole in pipe open and ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No near top of tank? 5 . Ball float pipe proper length to restrict flow at 90% ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No capacity? * * * A "No" to any item in Lines 1-5 indicates a test failure. Test Results ❑ Pass ❑ Fall ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail TEI Pass ❑ Fail Comments: * Use manufacturer's suggested procedure for determining if automatic shutoff device will shut off flow at 95 % capacity. ** If a ball float is found to fail the inspection , another method of overfill must be used. * * * Use manufacturer's suggested procedure for determining if flow restriction device will restrict flow at 90% capacity. Tester's Name ( print) Tester's Signature pei .org