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UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM <br /> Type of Action : ❑ Installation Inspection ❑ Repair Inspection ® 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment <br /> Inspection 9/27/2019 <br /> Business Name ACCO Trinity <br /> Business Site Address 10715 Trinity Pkwy City Stockton Zip Code <br /> ll . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Service Technician (on ICC Certification ) Darnell Smith Phone fl 916-371-2380 <br /> Contractor License f! : 433159 ICC Certification : 8709494 ICC Expiration Date : 12/21/2019 <br /> Overfill Prevention Equipment Relevant Certifications ( List Applicable) : <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑ Manufacturer Guidelines (Specify) : <br /> Used : <br /> ® Industry Code or Engineering Standard (Specify) : PEI 1200 Pg. 18 <br /> ❑ Engineered Method (Specify) : <br /> Attach the inspection procedures and all documentation required to determine the results. ik of attached pages : <br /> Tank ID : ( By tank number, stored 91 DSL <br /> What is the tank inside diameter? ( inches) 119 " 119 " <br /> Is the Fill Piping Secondarily contained ? ® Yes ❑ No ® Yes [:] No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the Vent Piping Secondarily contained ? ® Yes ❑ No ® Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment OPW OPW <br /> Manufacturer <br /> Tank Manufacturer Xerxes Xerxes <br /> What is the overfill prevention equipment ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> response when activated ? ® Restricts Flow ® Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ( Check all that apply) ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ❑ No <br /> piping? <br /> At what level in the tank is the overfill <br /> prevention set to activate? ( Inches from 1031/211 1031/211 <br /> bottom of tank. ) <br /> What is the percent capacity of the tank at <br /> which the overfill prevention equipment 94% 94% <br /> activates ? <br /> Is the overfill prevention in proper ® Yes ® Yes ❑ Yes ❑ Yes <br /> operating condition to respond when the <br /> ❑ No (Specify in V. ) ❑ No ( Specify in V. ) ❑ No (Specify in V. ) ❑ No (Specify in V. ) <br /> substance reaches the appropriate level ? <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ® Pass ❑ Fail I ® Pass ❑ Fail ❑ Pass [:] Fail ❑ Pass ❑ Fail <br /> V. COMMENTS <br /> Any items marked 'Fail" must be explained in this section. Any additional comments may also be provided here. <br /> 9/27/ 19 Unable to verify ball float on DSL tank, will need to return and trouble shoot . <br /> 10/ 18/ 19 - Pulled siezed plug and verified no ball float . <br /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipment was inspected in accordance with Califorrile4ode of Regulations, Title 23, <br /> Division 3, Chapter 16, Section 2637 . 2 and all the information contained herein is accurate . <br /> UST Service Technician SignatureIllow <br /> OU 019 <br /> i <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />