Laserfiche WebLink
UNDERGROUND STORAGE TANK <br /> OVERFILL PREVENTION EQUIPMENT INSPECTION REPORT FORM (Page 1 of 1 ) <br /> Typeof Action F1Installation Inspection El Repair Inspection Z 36 Month Inspection <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Overfill Prevention Equipment Inspection <br /> 10182305 12/6/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> PACIFIC CAR WASH <br /> Business Site Address City ZIP Code <br /> 4405 PACIFIC AVENUE STOCKTON 95207 <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 /> Zane Nimmo ( 209 ) 744- 0112 <br /> Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 04- 1676 Ex . 03/31 /2019 8883064- UT 6/ 1 /2019 ,,.e <br /> Overfill Prevention Equipment Inspection Training and Certifications (List applicable certifications.) <br /> FF- EBW , PhikTite & EVR Phase 1 10009843708 Ex 11 -29 -20 OPW 104-632 Ex 3- 14-20 >' - <br /> Emco 3206 Ex . 11 / 14/2020 ATG : VR : A28446 Ex . 9/28/ 19 Incon # 1009843708 Ex . 11 -3Vnl 0 _} <br /> III . OVERFILL PREVENTION EQUIPMENT INSPECTION INFO 16N O� <br /> Inspection Method Z Manufacturer Guidelines (Specify) :UseO P W PHASE I <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> ❑ Engineered Method (Specify) : � p <br /> Attach the inspection procedures and all documentation required to determine the results. # of Attached Pages 4 <br /> TANK ID : (By tank number, stored product, etc.) 1 - 87 OCT 2 - 91 OCT <br /> What is the tank inside diameter? (Inches) 112 . 0 112 . 0 <br /> Is the fill piping secondarily contained ? ❑ Yes ❑x No ❑ Yes Z No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Is the vent piping secondarily contained ? ❑ Yes R No ❑ Yes ❑x No ❑ Yes ❑ No ❑ Yes ❑ No <br /> Overfill Prevention Equipment Manufacturer(s) oPW o P W <br /> What is the overfill prevention equipment response ❑x Shuts Off Flow Z Shuts Off Flow ❑ Shuts Off Flow ❑ Shuts Off Flow <br /> when activated ? <br /> (Check all that apply.) El Restricts Flow ❑ Restricts Flow El Restricts Flow El Restricts Flow <br /> ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm ❑ AN Alarm <br /> Are flow restrictors installed on vent piping ? ❑ Yes 0 No ❑ Yes Z 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.) 102 . 0 101 . 0 <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 95 95 <br /> Is the overfill prevention in proper operating condition It 0 Yes Z Yes ❑ Yes ❑ Yes <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 Q Pass ElFail 0 Pass ❑ Fail ElPass E] Fail E] 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 Council, AN = Audible and Usual <br />