COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

UNDERGROUND STORAGE TANK OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Pagel of 1) Type of Action ❑ Installation Inspection ❑Repair Inspection ❑x 36 Month Inspection I. FACILITY INFORMATION CERS ID Date of Overfill Prevention Equipment Inspection 10182157 1115119 Business Name(Same as Facility Name or DBA-Doing Business As) KAMAL BROS TIGER EXPRESS Business Site Address MOCKTON ZIP Code 5777 FRENCH CAMP RD 95231 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Inspection(Print as shown an the]CC Certification.) Phone# Edward Stearns 1 (209) 744-0112 Contractor 1 Tank Tester License# ]CC Certification# ICC Certification Expiration Date 14-1760 Ex. 09/30/2020 8883080-UT 11/9/2020 Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) FF- EBW , Phil-Tite &EVR Phase 1 1009893708 Ex 11/29/2020 OPW 104-635 Ex 3-14-2020 ¢ Emco 3205 Ex. 11/16/2020 ATG:VR A31048 Ex.819119 Incon 1009893708 111301 a III. OVERFILL PREVENTION EQUIPMENT INSPECTION I ,)Old .--� r Inspection Method ❑x Manufacturer Guidelines(Specify): REMOVED AND INSPECTED Used: ❑ Industry Code or Engineering Standard(Specify): ❑Engineered Method (Specify): ENVIRONMEN- T Attach the inspection procedures and all documentation required to determine the results. #ot" a6hgU P666s 5 TANK ID:(By tank number,stored product,etc.) 87 91 DIE S DIE N What is the tank inside diameter?(inches) 114 114 114 114 Is the fill piping secondarily contained? ❑Yes 0 No ❑Yes 0 Nox No Yes ❑x No ❑Yes ❑ El Is the vent piping secondarily contained? ❑Yes 0 No ❑Yes ❑x No ❑Yes 9 No ❑Yes 2 No Overfill Prevention Equipment Manufacturer(s) OPW OPW OPW OPW What is the overfill prevention equipment response ❑x Shuts Off Flow ❑x Shuts Off Flow Z Shuts Off Flow 0 Shuts Off Flow when activated? (Check all that apply.) ❑Restricts Flow ❑ Restricts Flow ❑ Restricts Flow ❑Restricts Flow ❑AN Alarm ❑AIV Alarm ❑AN Alarm ❑AIV Alarm Are flow restrictors installed on vent piping? ❑Yes 0 No ❑Yes D No ❑Yes 2 Nox ❑Yes ❑No At what level in the tank is the overfill prevention set to activate?(inches from bottom of tank.) 102 102 102 102 What is the percent capacity of the tank at which the overfill prevention equipment activates? 90 90 91.5 91.5 Is the overfill prevention in proper operating condition ❑x Yes ❑x Yes Ox Yes Q Yes to respond when the substance reaches the appropriate level? ElNo(Specify in V.) ❑No(Specify in V.) ElNo(Specify in V.) 71No(Specify in V.) IV. SUMMARY OF INSPECTION RESULTS Overfill Prevention Inspection Results IF 0 Pass 0 Fail ❑x Pass ❑ Fail-A ❑x Pass ❑Fail 0 Pass ❑ Fail V. COMMENTS Any items marked"t=ail"must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION I hereby certify thatthe overfill prevention equipment was 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 �T If the facility has more components than this form accommodates,additional copies of this page maybe attached. CERS=Calilomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intemational Code Coundl,AN=Audible and Usual