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r((`I) PEI/RP1200-17 ----— - --- -- - — — – - ---- APPENDIX C-5 UST OVERFILL EQUIPMENT INSPECTION AUTOMATIC SHUTOFF DEVICE AND BALL FLOAT VALVE 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 PEI/RP1200 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.Droptube removed from tank? []Yes 0 N EI Yes 11 No ❑Yes El No ❑Yes El No El Yes 0 N El Yes El 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)? S.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 leak-free? 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? 5.13all 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 ❑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 0 pei.org