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UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page i of i ) Type of Action Instalistion Inspection [3 Repair Inspection 0 36 Month Inspection I. FACILITY INFORMATION CERS ID � � Date of Overfill Prevention equipment Inspection Business Name (Same as Faciiky Name or DBA-Doing Business As)IIIIIIIIIIIIIIIIIN n Business Site AddressCity ZIP Code I vc> T' bra l2 kd o D Z Ii. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICc Cord icaflon.) Phone # VAV E I2. c e 91 (otA111a Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date z Overfill Prevention Equipment Inspection Training and Certifications (List applicable celcations.) III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method IZManufacturer Guidelin4s (Specify): Used: e� lNSTRrI N titCe /NS @T1ort) S ❑ 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.) t i E Cj e t What is the tank Inside diameter? (Inches) Is the fill piping secondarily contained ? ❑ Yes fZ(' No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? ❑ Yes ZNo ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) What is the overfill prevention equipment response Ca Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Oft Flow when activated? f$j 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 KNo ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set It to activate? (Inches from bottom of tank.) gj What is the percent capacity of the tank at which the �y overfill prevention equipment activates? '"1 Is the overfill prevention in proper operating =the s ❑ Yes ❑ Yes ❑ Yes to respond when the substance reacm V.appropriate level? (Speci/y In V.) ❑ No (Specify In V.) ❑ No (Specify in V.) ❑ No (Specify ' ) IV. SUMMARY OF INSPECTION RESULTS overfill Prevention Inspection Results Pass ❑ Fail [3Pass ❑ Fail ❑ Pass ❑ Fall ❑ Pass (] Fail V. COMMENTS Any Items marked "Fail" must be explained in this section. Any additional comments hgm � J III III WWII I WIN Vi. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION William MINE 1 hereby certify that the overfill prevention equipment was inspected In accordan 64 th, all r�iCls-ba ibf Itey (latlpltt , Title 23, Division 3, Chapter 18, Section 2637.2 and all Information contained herein Is accura 4, s"� "yr I � UST Service Technician Signature - K the facility has more components than this form co dates, add! mai capes of this pegs may be attached* CERS = C,aNforrda Fltvirrxtrnarttai Repa6ng System, ID = IderttlAcation, Storage Tar�lt, ICC = htternationai Coda Cortnd, AN = Aud�bie �