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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 /> 10181391 10/25/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> ST. JOSEPH'S HOSPITAL <br /> Business Site Address City ZIP Code <br /> 1800 N. CALIFORNIA STREET STOCKTON 95204 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of LIST Service Technician Performing the Inspection(Print as shown on the ICC Certification.) Phone# <br /> Zane Nimmo (209) 744-0112 <br /> Contractor Tank Tester License# ICC Certification# ICC Certification Expiration Dale <br /> 04-1676 Ex.0313112019 8883064-UT 6/1/2019 <br /> Overfill Prevention Equipment Inspection Training and Certifications(List applicable certifications.) <br /> FF- EBW, Phil-Tite &EVR Phase 1 10009843708 Ex 11-29-20 OPW 104-632 Ex 3-14-2020 <br /> Emco 3206 Ex. 1111,412020 ATG: VR:A28446 Ex. 9128119 Incon#1009843708 Ex.11-30-20 <br /> III. OVERFILL PREVENTION EQUIPMENT INSPECTION INFORMATION <br /> Inspection Method9x` Manufacturer Guidelines(Specify): <br /> Used: O P W PHASE I INSPECTION <br /> ❑Industry Code or Engineering Standard(Specify): <br /> ❑Engineered Method(Specify): <br /> Attach the inspection procedures and all documentation required to determine the results. #of Attached Pages 2 <br /> TANK ID:(By tank number,stored product etc.) RED DSL <br /> What is the tank inside diameter?(Inches) 118.5 <br /> Is the fill piping secondarily contained? ❑Yes 0 No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Is the vent piping secondarily contained? ❑Yes []No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> Overfill Prevention Equipment Manufacturer(s) oPw <br /> What is the overfill prevention equipment response p 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 /> ❑AIV Alarm ❑AiV Alarm ❑AIV Alarm ❑AlV Alarm <br /> Are flow restrictors installed on vent piping? ❑Yes p No ❑Yes ❑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.) 98.5" <br /> What is the percent capacity of the tank at which the <br /> overfill prevention equipment activates? 88.2% <br /> Is the overfill prevention in proper operating condition Yes ❑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(Specifyin V.) <br /> IV. SUMMARY OF INSPECTION RESULTS <br /> Overfill Prevention Inspection Results ❑x Pass ❑Fall I [--]Pass ❑Fail 1 ❑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 /> 19,807 MAX VOL. OWENS CORNING LIQUID FILLED ANNULAR. <br /> VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS INSPECTION <br /> I hereby certify thatthe 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 fhan this form accommodates,additional copies of this page may be attached. <br /> CERS=CaTifomia Environmental Reporting System,ID=kientifica6on,UST=Underground Storage Tank,ICC=International Code Cound,AA/=Audible and Visual <br />