Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Type of Action ❑ Installation Inspection ❑ Repair Inspection ❑x 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10063345 1 /25/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> FAST LANE GAS TEST FORM 2 of 2 <br /> Business Site Address City ZIP Code <br /> 116 ROTH RD LATHROP 95330 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Inspection (Print as shown on the ICC Certification.) Phone # <br /> Felix Ramirez ( 209 ) 744- 0112 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 08 - 1740 Ex . 03/31 /2020 8883072- UT 11 /9/2020 <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> _ <br /> FF- FF- EBW , Phil-Tite & EVR Phase 1 1009883708 EX 11 -29-20 OPW 104-634 Ex 4 <br /> Emco 3147 Ex . 11 - 16-20 VR : B34976 ATG : 7/7/20 Incon 1009883708 Ex 11 -30-20 = s <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method ❑x Manufacturer Guidelines (Specify) : ATG VRIf <br /> Used : <br /> ❑ Industry Code or Engineering Standard (Specify) : f�i� LT H <br /> IS�rON � �s°'i�w i� � <br /> ❑ Engineered Method (Specify) : .� �'i4 <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 6 <br /> TANK ID : (By tank number, storedproduct, etc.) EEE DIESEL 2 <br /> What is the tank inside diameter? (Inches) 119 . 75 <br /> Is the fill piping secondarily contained? ❑x Y0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? 0 Y0 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) VEEDER <br /> ROOT ROOT <br /> What is the overfill prevention equipment response ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑ Restricts Flow <br /> ❑x A/V Alarm ❑x A/V Alarm ❑ A/V Alarm ❑ A/V Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes ❑X No ❑ Yes ❑ No ❑ Yes ❑ No <br /> At what level in the tank is the overfill prevention set <br />� to activate? (Inches from bottom of tank.) 100 100 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 90 % 90 % <br /> Is the overfill prevention in proper operating condition ❑x Yes M Yes ElYes ElYes <br /> to respond when the substance reaches the <br /> appropriate level ? ❑ No (Specify in V) ❑ No (Specify in V) ❑ No (Specify in V.) ❑ No (Specify in V) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑ Fail Z 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 /> VI . CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify that the overfill prevention equipmentwas inspected in accordance with California Code of Regulations , Title 23 , <br /> Division 3 , Chapter 16 , Section 2637 . 2 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> If the facility has more components than this form accommodates, additional copies of this page may be attached. <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Coundl, AA/ = Audible and Usual <br />