COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

U E042 UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) FTypef Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10198666 7/9/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Pacific Bell Telephone Co . dba AT&T California Business Site Address City ZIP Code 345 N . San Joaquin Stockton 95202 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # Gage Hart (714) 560-8222 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 588098 18361014 5/8/2021 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) Veeder root TLS -XX Technician III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑ Manufacturer Guidelines (Specify) : Used : ❑x Industry Code or Engineering Standard (Specify) : PEI RP1200 ❑ 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.) UE0420001 What is the tank inside diameter? (Inches) 119 . 750 Is the fill piping secondarily contained ? ❑x Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Is the vent piping secondarily contained? x Y No Yes No ❑ Yes ❑ No ❑ Yes ❑ No P P 9 Y ❑ es ❑ ❑ ❑ Overfill Prevention Equipment Manufacturer(s) Veeder- Root What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow when activated ? ❑ (Check all that apply.) Restricts Flow ❑ Restricts Flow El Restricts Flow [I Restricts Flow ❑Q AN Alarm ❑ AN Alarm ❑ AIV Alarm ❑ A/V Alarm Are flow restrictors installed on vent piping ? ❑ Yes ❑x 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.) 100 . 750" What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 % Is the overfill prevention in proper operating condition ❑x Yes ❑ Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level? 0, ❑ No (Specify in V.) ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results ❑x Pass ❑ Fail I ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail V. COMMENTS Any items marked "Fail" must be explained in this section. Any additional comments may also be provided here. El Check If Action Item (s) Are Present VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify that the overfill prevention equipmentwas 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 61we- ;1/.t� 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 = Intemational Code Council, AV = Audible and Visual