COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM ( Page 1 of 1 ) Type of Action ❑ Installation Inspection ❑ Repair Inspection Z 36 Month Inspection I . FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10726990 10/ 11 /2018 Business Name (Same as Facility Name or DBA-Doing Business As) Pilot 1017 fuslne s. ifelQg4ut9� zit' Code �45 ` f oli , fo d ' _ 77T!Lathrop. 95330 - II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection (Print as shown on the ICG Certification.) Phone # Rogello Valencia ( 888 ) 972 -7581 IIIIIIIIqq Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 804431 825764MT 4/20/2020 Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) OPW #167223 Exp . 1 /19/20 III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION Inspection Method ❑x Manufacturer Guidelines (Specify) : Step by step instructions on measurements and how to cut . Used : ❑ Industry Code or Engineering Standard (Specify) : ❑ Engineered Method (Specify): v*of Atteched Wages , Attach the Inspection procedures and all documentation rogn1rod to dateftinb the results. ` 4 `rAIJK .II) : (By tank ndi lber, stored product, etc.) IT# 2 91 What is the tank Inside diameter? (inches) 120" is the fill piping secondarily contained? Yes ❑ No d Yes ❑ No ❑ Yes t] No [1 Yes 0 No Is the vent piping secondarily containe ? M Yes ❑ No d Yes ❑ No CI Yes ❑ No ❑ Yes ❑ No Overfill Prevention Equipment Manufacturer(s) opw oPw What is the overfill prevention equipment response Z Shuts Off Flow I] Shuts Off Flow ❑ Shuts Oft Flow ❑ Shuts Off Flow when activated? (Check all that apply.) E] Restricts Flow ❑ Restricts Flow ElRestricts Flow ElRestricts Flow EJ AtV Alarm ❑ AIV Alarm ❑ AN Alarm ❑ AN Alarm Are flow restrictors installed on vent piping ? ❑ Yes [E] No ❑ Yes FRWI No ❑ Yes ❑ No ❑ Yes ❑ No At what level in the tank is the overfill prevention set 1061 /8 1067/8 to activate? (Inches from bottom of tank.) E' i. What is the percent capacity of the tank at which the overfill prevention equipment activates? 95 % 95 % Is the overfill prevention in proper operating condition I ❑x Yes 0 Yes ❑ Yes ❑ Yes to respond when the substance reaches the appropriate level? ❑ No (Specify in V) ❑ No (Specify in V) ❑ No (Specify in V) ❑ No (Specify in V.) IV. SUMMARY OF INSPECTION RESULTS IIIIIIIIN Overfill Prevention Inspection Results ❑x Pass ❑ Fail 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 . Site equipped with OPW drop tube overfill prevention set at 95% 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 If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = Cai'ifomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, AN = Audible and Visual