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r(C`1� PEURP1200-17 APPENDIX C-5 UST OVERFILL EQUIPMENT INSPECTION AUTOMATIC SHUTOFF DEVICE AND BALL FLOAT VALVE Facility Name: Owner: Address: Address: City,State,Zip Code: City,State,Zip Code: Facility I.D.#: Phone#: Testing Company: Phone#: Date: This data sheet is for inspecting automatic shutoff devices and ball float valves.See PEI/RP1200 Section 7 for inspection procedures. Product Grade Tank Number Tank Volume,gallons Tank Diameter,inches Overfill Prevention Device Brand Type ❑Automatic ❑Automatic ❑Automatic ❑Automatic ❑Automatic ❑Automatic Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device Shutoff Device ❑Ball Float ❑Ball Float ❑Ball Float ❑Ball Float ❑Ball Float ❑Ball Float Valve Valve Valve valve Valve Valve AUTOMATIC SHUTOFF DEVICE INSPECTION 1.Drop tube removed from tank? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No 2.Drop tube and float mecha- ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No nisms free of debris? 3.Float moves freely without binding and poppet moves into ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No flow path? 4.Bypass valve in the drop tube ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No open and free of blockage(if ❑Not Present ❑Not Present ❑Not Present ❑Not Present ❑Not Present ❑Not Present present)? 5.Flapper adjusted to shut off ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No flow at 95%capacity?* A"No"to any item in Lines 1-5 indicates a test failure. BALL FLOAT VALVE INSPECTION** 1.Tank top fittings vapor-tight ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No and leak-free? 2.13all float cage free of debris? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑Nc ❑Yes ❑No ❑Yes ❑No 3.13all free of holes and cracks ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No and moves freely in cage? 4.Vent hole in pipe open and ❑Yes D No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No near top of tank? 5.Ball float pipe proper length to restrict flow at 90% ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No capacity?*** A"No"to any item in Lines 1-5 indicates a test failure. Test Results ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail Comments: *Use manufacturer's suggested procedure for determining if automatic shutoff device will shut off flow at 95%capacity. **If a ball float is found to fail the inspection,another method of overfill must be used. ***Use manufacturer's suggested procedure for determining if flow restriction device will restrict flow at 90%capacity. Tester's Name(print) Tester's Signature 0 pei.org