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Appendix IX UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1) Type of Action ❑ Installation Inspection ❑Repair Inspection ❑36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection Business Name(Same as Facility Name or DBA-Doing Business As.) Business Site Address City ZIP Code II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone# Contractorrrank Tester License# ICC Certification# ICC Certification Expiration Date Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method Used: ❑Manufacturer Guidelines(Specify) ❑ Industry Code or Engineering Standard (Specify) ❑ Engineered Method (Specify) Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages Tank ID: (By tank number,stored product,etc.) What is the tank inside diameter?(Inches) Is the fill piping secondarily contained? ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑No Is the vent piping secondarily contained? ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑ No ❑Yes ❑ No Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow ❑Shuts Off Flow response when activated? ❑ Restricts Flow ❑Restricts Flow ❑Restricts Flow ❑ Restricts Flow (Check all that apply.) ❑AN Alarm ❑AN Alarm ❑AN Alarm ❑AN Alarm Are flow restrictors installed on vent piping? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑ No ❑Yes ❑ No At what level in the tank is the overfill prevention set to activate?(Inches from bottom of tank.) What is the percent capacity of the tank at which the overfill prevention equipment activates? Is the overfill prevention in proper operating ❑Yes ❑Yes ❑Yes ❑Yes condition to respond when the substance ❑No ❑ No ❑No ❑No reaches the appropriate level? (Specify in section V.) (Specify in section V.) (Specify in section V.) (Specify in section V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑Pass [:] Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS All items marked"Fail'must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipment was inspected in accordance with California Code of Regulations,title 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, AN=Audible and visual